Top Three Skill Sets: Customer Service, Computer Skills and medical terminology
Job Description:
Provide computer entries of authorization request/provider inquiries by phone, mail, or fax. Including: Verify member eligibility and benefits, Determine provider contracting status and appropriateness, Determine diagnosis and treatment request Assign billing codes (ICD-9/ICD-10 and/or CPT/HCPC codes), Determine COB status, Verify inpatient hospital census-admits and discharges, Perform action required per protocol using the appropriate Database.
Respond to requests for authorization of services submitted to CAM via phone, fax and mail according to Client's operational timeframes.
Participates in interdepartmental integration and collaboration to enhance the continuity of care for Client members including Behavioral Health and Long Term Care.
Contact physician offices according to Department guidelines to request missing information from authorization requests or for additional information as requested by the Medical Director.
Provide excellent customer service for internal and external customers.
Meet department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores.
Notify Care Access and Monitoring Nurses and case managers of hospital admissions and changes in member status.
Meet productivity standards.
Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
EDUCATION:
Accurate data entry at 40 WPM minimum.
Required Education: High School Diploma/GED
Required Experience: 1-4 years of experience in a Utilization Review Department in a Managed Care Environment.
Previous Hospital or Healthcare clerical, audit or billing experience. Experience with Medical Terminology