This position supports the Health Services and Utilization Management functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators.
- Handles initial screening for pre-certification requests from physicians/members via incoming calls or correspondence based on scripts and workflows, and under the oversight of clinical staff.
- Performs review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients.
- Prepare, document and route cases in appropriate system for clinical review.
- Must be able to navigate through applications and be comfortable working with computers
- Non Clinical staff members are not responsible for conducting any UM review activities that require interpretation of clinical information.
- Reviewing professional medical/claim policy related issues or claims in pending status.
- Initiates call backs and correspondence to members and providers to coordinate and clarify benefits.
- Upon completion of inquiries initiate call back or correspondence to Physicians/Members to coordinate/clarify case completion.
- Upon collection of clinical and non-clinical information MCC can authorize services based upon scripts or algorithms used for pre-review screening.
- Perform other relevant tasks as assigned by Management.
- MCC for inpatient calls, connect with provider, check eligibility and benefits, reviews
- Being on phone, setting for rehabilitation
- Medical Management tools : Caradious, NAS, CPL, TPS
- Education: High School Diploma required. Some College preferred.
- Prefer 1-2 years customer service or medical support related position.
- Prefer the ability to use a personal computer and applicable software and systems
- Prefer knowledge Managed Care principles
- Requires ability to make sound decisions under the direction of Supervisor
- Requires knowledge of medical terminology
- Prefer knowledge of contracts, enrollment, billing & claims coding/processing