Share this Job
Apply now »

EyeMed - Utilization Management Specialist

Date:  Jun 5, 2021
Brand:  EyeMed Vision Care
Location: 

Mason, OH, US, 45040

Requisition ID: 379961 
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, Target Optical and Sears 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 Management is responsible for collaboration with the RN Nurse reviewers, Peer Clinical Reviewers and/or Medical Director to ensure all notifications are communicated to the member or provider accurately and timely. The Specialist- Utilization Management works closely with the UM Manager and Medical Director to manage appeals for services that denied, interpreting appropriateness of case, accurate claims payment as part of the appeal processes.

  

MAJOR DUTIES AND RESPONSIBILITIES

  • Completes outbound phone call communication to member and providers
  • Review and revise, as necessary, written member and provider notifications regarding prior authorization determinations
  • Consults with nurse reviewers, peer clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the utilization management process.
  • Prepare and summarize case files for appeal request reviews, external reviews or forwarding to health plans
  • Maintains record and documents results of the clinical review and determination in the appropriate system.
  • Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
  • Maintains awareness of industry trends and developments related to utilization management and the measurement of vision care quality and cost efficiency.
  • Maintains confidentiality for patient data and provider specific information.

 

BASIC QUALIFICATIONS

  • Requires a current, active, unrestricted LPN license issued by a U.S. state(s) or territory
  • Requires at least 2 years acute care clinical experience.
  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
  • Must be proficient in Microsoft Office (Access, Excel, PowerPoint, Word)
  • Ability to work independently under general instructions and with a team
  • Knowledge of and experience with Medicaid and Medicare regulations
  • Strong organization and multi-tasking skills
  • Demonstrated ability to meet deadlines
  • High sense of urgency
  • Flexible working hours

 

PREFERRED QUALIFICATIONS

  • 2+ years Utilization Management experience in managed care, acute, or rehab setting desired
  • Experience with criteria tools (i.e. Milliman Care guidelines, Interqual or Medicare Local Coverage Determination guidelines)
  • Knowledge of utilization review process and prior authorization process in a managed health care industry
  • Prior supervisory or management experience
  • Prior participation in URAC/NCQA accreditation activities

 

Upon request and consistent with applicable laws, Luxottica 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 Luxottica Ethics Compliance Hotline at 1-888-887-3348 or e-mail HRCompliance@luxotticaretail.com (be sure to provide your name and contact information for either option so that we may follow up in a timely manner). 

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 receive preference in accordance with Tribal Law.


Nearest Major Market: Cincinnati

Job Segment: Manager, Rehabilitation, Medical, Medicare, Medicaid, Management, Healthcare

Apply now »