Must have at least 1 year of Medical Management Experience (MMC)
Must have off-entry and processing experience.
Will be handling and processing Utilization and authorization request via FAX only
Supports the Utilization Management clinical teams by assisting with non-clinical administrative tasks and responsibilities related to pre-service, utilization review, care coordination and quality of care. This position will require the individual to work thirty-two hours during the business week and eight hours on weekends.
ESSENTIAL FUNCTIONS:
Performs member or provider related administrative support which may include benefit verification, authorization creation and management, claims inquiries and case documentation.
Reviews authorization requests for initial determination and/or triages for clinical review and resolution.
Provides general support and coordination services for the department including but not limited to answering and responding to telephone calls, taking messages, letters and correspondence, researching information and assisting in solving problems.
Assists with reporting, data tracking, gathering, organization and dissemination of information such as Continuity of Care process and tracking of Peer to Peer reviews.
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable
accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education Level: High School Diploma
Experience: 3 years experience in health care claims/service areas or office support.
Preferred Qualifications
Two years' experience in health care/managed care setting or previous work experience within division
Knowledge of CPT and ICD-10 coding.
Knowledge, Skills and Abilities (KSAs)
Ability to effectively participate in a multi-disciplinary team including internal and external participants., Proficient
Excellent communication, organizational and customer service skills. , Proficient
Knowledge of basic medical terminology and concepts used in managed care., Proficient
Knowledge of standardized processes and procedures for evaluating medical support operations business practices., Proficient
Excellent independent judgment and decision-making skills, consistently demonstrating tact and diplomacy. , Proficient
Ability to pay attention to the minute details of a project or task, Proficient
Experienced in the use of web-based technology and Microsoft Office applications such as Word, Excel, and Power Point, Proficient
Additional Skills: Guiding Care, Facets, Nice
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