Utilization Management Specialist

Requisition ID:873171

Position:Full-Time

Total Rewards:Benefits/Incentive Information

There's more to EyeMed than meets the eye. EyeMed is the fastest growing managed vision benefits company in the country with consistent double-digit membership growth! Through our commitment to innovation, we're reimagining the way employers and their employees think about vision care. We want them to see life to the fullest and experience more of what's best, not more of the same. And if what's best hasn't been done yet, it's our exceptional and passionate employees driving this change. But, our passion for vision isn't just about vision insurance benefits. Our employees are proud to support and participate in life-altering global and local missions through our partnership with OneSight, a leading not-for-profit organization with a 100% focus on eradicating the world's vision crisis.

Your family says a lot about who you are. EyeMed is a key member of the Luxottica family of companies, global leaders in the design, manufacture and distribution of fashion, luxury and sports eyewear. In North America, Luxottica is the home to global brands Ray-Ban, Oakley and many top fashion house brands. Our leading retail brands include LensCrafters, Sunglass Hut, Pearle Vision, and Target Optical.

If you're passionate about driving innovation and change and interested in a career in the optical and insurance industry, EyeMed wants to start the conversation and help provide you a growth-focused opportunity with America's fastest growing vision benefits company.

GENERAL FUNCTION

The Specialist- Utilization is responsible for providing administrative support to utilization management operations, which includes handling the most complex file reviews and inquiries from members and providers.

MAJOR DUTIES AND RESPONSIBILITIES

• Gathers clinical information regarding cases and determines appropriate area to refer or assign case (utilization management, QA, appeals).
• Conducts initial review of files to determine appropriate action
• Maintains and updates tracking
• Prepares reports and documents all
• Responds to requests, calls or correspondence within
• Makes outbound calls to members and providers within
• Provides general program information to members and providers as
• Acts as liaison between utilization management operations and other internal departments to support ease of administration of medical and vision
• Interact and coordinate with nurse reviewers and clinical peer reviewers
• Consults with a nurse reviewer, clinical peer reviewer or the Medical Director with questions
• Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information.
• Prepare case files for external reviews or forwarding to health plans
• Creates and manages reports that support key constituents, including clients and other EyeMed associates.
• Maintains record and documents results of the clinical review and determination in the appropriate system
• Maintains confidentiality for patient data and provider specific information
• Maintain awareness of industry trends and developments related to utilization management and the measurement of vision care quality and cost efficiency.
• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

BASIC QUALIFICATIONS

• Associate's Degree or equivalent work experience
• LPN
• 3 years of experience in health care administration and/or utilization management with knowledge of Medicaid/Medicare concepts
• Experience with medical terminology and medical coding
• Strong written and oral communication skills
• Proficient in Microsoft Office (Access, Excel, PowerPoint, Word)
• Strong organization and multi-tasking skills
• Demonstrated ability to meet deadlines
• High sense of urgency

PREFERRED QUALIFICATIONS

• RN
• Experience in an eye care provider setting
• Experience participating in external audits
• Experience in Project Management
• Ability to manage time and tasks independently

Employee pay is determined by multiple factors, including geography, experience, qualifications, skills and local minimum wage requirements. In addition, you may also be offered a competitive bonus and/or commission plan, which complements a first-class total rewards package. Benefits may include health care, retirement savings, paid time off/vacation, and various employee discounts.

Upon request and consistent with applicable laws, EssilorLuxottica will provide reasonable accommodations to individuals with disabilities who need assistance in the application and hiring process. To request a reasonable accommodation, please call the EssilorLuxottica SpeakUp Hotline at 844-303-0229 (be sure to provide your name and contact information so that we may follow up in a timely manner) or email HRCompliance@luxotticaretail.com.

We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, gender, national origin, social origin, social condition, being perceived as a victim of domestic violence, sexual aggression or stalking, religion, age, disability, sexual orientation, gender identity or expression, citizenship, ancestry, veteran or military status, marital status, pregnancy (including unlawful discrimination on the basis of a legally protected pregnancy or maternity leave), genetic information or any other characteristics protected by law. Native Americans in the US receive preference in accordance with Tribal Law.