Utilization Review Representative II
ECCA - San Antonio, TX

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We are currently seeking a Utilization Review Representative II, to promote favorable company relationships with customers, providers, and groups through the prompt, accurate and courteous resolution of prior approval and medical necessary requests. Maintain compliance with applicable regulatory requirements. Under general supervision, point of contact between the company, client and or health care professional.

  • Responsible for the coordination and process of prior approval/medically necessary contact lens requests, which includes, but is not limited to, logging, faxing, copying, and filing etc.
  • Receive, review and process prior approval requests in accordance to company and regulatory agency standards.
  • Prepare requests for medically necessary contact lenses with supporting documentation for review by professional peer reviewer(s) within company, client and regulatory agency timeframes.
  • Respond quickly and professionally to requests for prior approval and/or medically necessary contact lens while maintaining required client performance standards.
  • Notify members, providers and clients as required using approved documents and or via telephone.
  • Provide timely and accurate follow-up to associate, client and/or health care professionals as needed.
  • Responsible for coordinating the prior approval/medically necessary processes to meet all client performance guarantees.
  • Responsible to ensure that files are documented with appropriate information (i.e. date stamped, signed, etc.).
  • Assist with and perform quality control assessment.
  • Assist with audit request and preparation.
  • Participate in special projects.
  • May serve as point of contact for department in Managers absence.

  • Work Environment:
  • Office Environment

  • Requirements:
  • Two years in related field
  • Intermediate to advanced computer skills to include: Microsoft Word, Excel, and Outlook

  • Education:
  • High School Degree required
  • Associate or Bachelor degree preferred

  • Experience:
  • Two years in related field
  • Ability to understand optical Rx a plus.
  • Familiarity with medical technology a plus.
  • Experience in call center and customer service is highly desirable.

  • Benefits:
    • Medical Insurance
    • Employee Assistance Program
    • Dental Insurance
    • Company paid Life and AD&D policy with optional insurance coverage available
    • Short and Long Term Disability
    • 401K participation
    • Free Associate Eyewear Program & Family Discount Program
    • Paid Vacation
    • Paid Personal Days
    • Paid Holidays