Offer summary

Qualifications:

High School Diploma required; Associate's Degree preferred., 1-3 years of experience in the healthcare industry, preferably in health insurance., Strong understanding of medical terminology, coding (ICD-9, HCPCS, CPT4), and claims adjudication., Proficient in MS Office applications and various healthcare data systems..

Key responsibilities:

Evaluate and distribute incoming requests within the department.

Coordinate prior approval and pre-certification requests across multiple systems.

Communicate with members and providers regarding service requests and medical records.

Ensure compliance with NCQA and URAC standards through quality assurance of correspondence.

Job description

Our Client, a Health Insurance company, is looking for a Clinical Support Representative for their Remote location.

Responsibilities:

Evaluate incoming requests and determine proper distribution throughout the department and company.
Analyze and research requests to determine client, TVHP, FEP & NEHP member/benefit eligibility, including identifying OPL, waiting periods, benefit maximums, etc.
Coordinate requests and create cases for prior approval and pre-certification in multiple systems (including: Customer Focus, Acuity, MHS, AS400) for review by clinical reviewers.
Identify and refer members for case management based on diagnoses and types of service being requested.
Enter and update authorizations to ensure appropriate claims processing based on clinical reviewers’ decision.
Correspond with members and providers regarding decisions about requested services and to obtain medical records when necessary.
Participate in on-going efforts to comply with NCQA, Rule 10 and URAC standards by performing quality assurance of outgoing correspondence, understanding time variations of requirements and responding to requests within the timeliness guidelines.
Work collaboratively with other departments to obtain additional information to resolve claims, inquiry, and prior approval/pre-certification requests.
Professionally and courteously answer, manage and appropriately route department telephone calls, processing calls regarding pre-certification and prior approval of services and referring to other departments when necessary.
Review and respond to issues and questions from internal and external customers, both verbally and in writing.
Act as a liaison between the Plan’s members, outside vendors and providers, and Blue Cross.
Acquire and implement a high level of professional and service excellence when interacting with all customers, external as well as internal.
Develop cooperative relationships both within and outside of the company.
Provide clear, concise, and accurate interpretation of Plan certificate language, benefit administration, and all information communicated to customers.
Manage electronic medical records and all incoming PHI, always maintaining the highest level of confidentiality.
Assist clinical staff in gathering data, researching claims/authorizations, obtaining medical records, and other duties as needed.

Requirements:

Understanding of plan benefits and products
Understanding of claims adjudication and data systems
Understanding of medical terminology and medical coding, to include ICD-9, HCPCS, and CPT4
Understanding of URAC, NCQA, Rule 10, DOL, and other regulatory standards pertaining to
Computer Skills: Competent in use of MS Office Applications (specifically Outlook, Word and Excel), AS400 legacy, MHS, Lotus Notes, Customer Focus, OnBase, The Knowledge Center, FEP Direct, web browsing, Acuity and phone system.
Strong written and oral communications skills, with advanced listening skills to be able to identify provider and subscriber concerns
1-3 years experience in the healthcare industry, preferably health insurance.
High School Diploma
Associates Degree preferred

Why Should You Apply?

Health Benefits
Referral Program
Excellent growth and advancement opportunities

As an equal opportunity employer, ICONMA provides an employment environment that supports and encourages the abilities of all persons without regard to race, color, religion, gender, sexual orientation, gender identity or express, ethnicity, national origin, age, disability status, political affiliation, genetics, marital status, protected veteran status, or any other characteristic protected by federal, state, or local laws.

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