Offer summary

Qualifications:

High school diploma or GED required; Associate's degree preferred., Minimum of six months experience in the medical field, preferably in a hospital, clinical, or insurance setting., Prior experience with obtaining authorizations and/or benefits from a Health Plan is preferred., Proficient in Microsoft programs and excellent keyboard and web navigation skills..

Key responsibilities:

Verify eligibility and benefit coverage for requested services.

Enter pre-service requests and authorizations into the clinical system and ensure all documentation is submitted.

Communicate authorization status to members and provide referrals to external providers.

Participate in departmental meetings and assist in the management of incoming and outgoing documentation.

Job description

Job Description Summary
This position performs non-clinical functions for the Utilization Management process. Facilitates department workflows by supporting the clinical team with various utilization requests. Effectively and efficiently manages a diverse workload in a fast-paced and rapidly changing environment.

• Verifies eligibility and/or benefit coverage for requested services.
• Enters pre-service requests and/or authorizations into clinical system using diagnosis codes and CPT coding; verifies all necessary documentation has been submitted.
• Answers queue calls relating to UM review and pre-service status.
• Provides referrals and authorization to external providers.
• Communicates authorization status to members
• Meets specific deadlines and prioritizes assignments according to department policies, standards and needs.
• Provides information required for denial letters for members whose benefits do not cover requested services
• Supports and facilitates teamwork within the department / group and the organization.
• Participates in scheduled departmental / group meetings.
• Requests necessary clinical information to ensure requests are properly set up for clinical review in the system. Troubleshoots when a provider, type of service or appropriate level of care cannot be readily found.
• Converts clinical information obtained from providers (received via fax, phone, web, e-mail or mail) into electronic records within the system.
• Facilitates and assists in completion of appropriate documentation and provider-related forms as needed.
• Assists the Utilization Management (UM) team in daily management of incoming and outgoing documentation.
• Redirects participating providers with out-of-network requests, if needed.
• Proactively seeks and participates in ongoing training (formal and informal) in all aspects of the UM coordinator role.
• Remains responsible for updating self on ever-changing information to ensure accuracy when dealing with members and providers.
• Coordinates and manages distribution of correspondence and materials to members and providers.
• Participates in operational activities, including data collection, tracking, and analysis.

Qualifications :
• HS diploma or GED required; Associates preferred.
• A minimum of six months experience in the medical field, either in a hospital, clinical or insurance setting required.
• Prior experience with obtaining authorizations and/or benefits from a Health Plan preferred.
• Excellent keyboard and web navigation skills and ability to use a variety of electronic information processing; Proficient in the use of Microsoft programs.
• Excellent skills in time management, including ability to manage priorities and complete assignments within designated timeframes; and be self-directed in a virtual work environment.
• Ability to collaborate with a virtual team.
• Develop and manage interpersonal relationships.