Utilization Review Specialist

ATHENS POSITION DETAILS Position Title: Utilization Review Specialist Department: Managed Care – Orange, CA Reports To: Utilization Review Clinical Supervisor FLSA Status: Non-Exempt Job Grade: 6 Career Ladder: Next step in progression could include Utilization Review Specialist II ATHENS ADMINISTRATORS Explore the Athens Administrators difference: We have been dynamic, innovative leaders in claims administration since our founding in 1976. We foster an environment where employees not only thrive but consistently recognize Athens as a “Best Place to Work.” Immerse yourself in our engaging, supportive, and inclusive culture, offering opportunities for continuous professional growth. Join our nationwide family-owned company in Workers' Compensation, Property & Casualty, Program Business, and Managed Care. Embrace a change and come make an impact with the Athens Administrators family today! POSITION SUMMARY Athens Administrators has an immediate need for a full-time Utilization Review Specialist to support our Athens Managed Care department and can be located remotely if technical requirements are met and the employee resides in a state Athens operates in. The schedule for this position is Monday-Friday from 9am – 5pm PST with a 30-minute meal break, 37.5 hours a week. The Utilization Review Specialist assists the utilization review process taking on various tasks including data collection of demographics, claim and medical information; non-medical analysis; and outcomes reporting. PRIMARY RESPONSIBILITIES Our new hire should have the skills, ability, and judgment to perform the following essential job duties and responsibilities with or without reasonable accommodation. Additional duties may be assigned: - Abundant data entry - Enters initial data and starts workflow processes - Initiates and modifies demographic information, physician, and facility information, performs quality check of data feed information - Validates that the request for authorization is complete or requests additional data from requesting physician if necessary - Run request for authorizations through rules engine for direct approval - Assign cases to next level reviewer if they do not meet criteria for direct approval - Answers general phone calls and/or emails in a professional manner and directs to the appropriate party as required - Complete other projects and tasks as assigned by management - Follow all regulatory policies and procedures, privacy, and security standards in accordance with government agencies including HIPAA requirements - Other duties as assigned ESSENTIAL POSITION REQUIREMENTS The requirements listed below are representative of the knowledge, skill, and/or ability required. While it does not encompass all job requirements, it is meant to give you a solid understanding of expectations. - High School Diploma or equivalent (GED) required for all positions - AA/AS or BA/BS preferred but not required - Minimum of one year data entry experience, preferably in medical or insurance industry - One year work experience in corporate environment preferred - Knowledge of, or ability to learn, and apply basic medical terminology and ICD-9/10 - One year customer service experience minimum - Time management skills and the ability to work independently to meet goals and sensitive timelines - Well-developed verbal and written communication skills with strong attention to detail - Excellent organizational skills and ability to multi-task - Ability to type quickly, accurately and for prolonged periods - Proficient in Microsoft Office Suite - Ability to learn additional computer programs - Reasoning ability, including problem-solving and analytical skills, i.e.,