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.
- 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.
- 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.
- Prepare, document, and route cases inappropriate system for clinical review.
- Initiates callbacks 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.
- Reviewing professional medical/claim policy-related issues or claims in pending status.
- 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
- High School Diploma required. Some Colleges preferred.
- Prefer 1-2 years of customer service or medical support-related position.
- Basic Excel skills
- Able to handle approx. 50-60 calls a day
- Knowledge of medical terminology be a plus
- Requires ability to make sound decisions under the direction of Supervisor
- Prefer knowledge of contracts, enrollment, billing & claims coding/processing
- Knowledge Managed Care principles
- Ability to use a personal computer and applicable software and systems