Care Review Processor

Job Description

Duties:

• Build waiver authorizations for members on Medicaid and Medicare.
• Providing authorization to providers so they can bill for the dual services.
• Will also work in claims flow, research for waiver for pending claims for waiver services.
• Heavy data entry. Will utilize QNXT, Care Advanced and Microsoft Outlook and Excel (beginning to intermediate level)
• A minimum 1 year of Managed care experience, Medical billing, within a healthcare background.
• Manager will consider candidate with no healthcare experience but has a 4 year college degree and willingness to learn.
• Training: Onsite classroom style training for 3 weeks.
• Expectation after training is to handle 20-25 claims per day.

Summary:

• Works within the Care Access and Monitoring (CAM) team to provide clerical and data entry support for Members that require hospitalization and/or utilization review for other healthcare services

• Checks eligibility and verifies benefits, obtains and enters data into systems, processes requests, and triages members and information to the appropriate Health Care Services staff to ensure the delivery of high quality, cost-effective healthcare services according to State and Federal requirements to achieve optimal outcomes for Members.

Essential Functions:

• Provide computer entries of authorization request/provider inquiries by phone, mail, or fax.
• Including: Verify member eligibility and benefits, o Determine provider contracting status and appropriateness, o Determine diagnosis and treatment requestAssign billing codes (ICD-9/ICD-10 and/or CPT/HCPC codes), o Determine COB status, o Verify inpatient hospital census-admits and discharges, o 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 operational timeframes. ? Participates in interdepartmental integration and collaboration to enhance the continuity of care for 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). ? Participate in Care Access and Monitoring meetings as an active member of the team. ? Meet attendance guidelines per Healthcare policy.
• Standards of Conduct Guidelines as described in Healthcare HR policy. Comply with required workplace safety standards.

Knowledge/Skills/Abilities:

• Demonstrated ability to communicate, problem solve, and work effectively with people. ? Working knowledge of medical terminology and abbreviations. ? Ability to think analytically and to problem solve. ? Good communication and interpersonal/team skills. ? Must have a high regard for confidential information. ? Ability to work in a fast paced environment. ? Able to work independently and as part of a team.

Qualifications

Additional Information

Feel free to forward my email to your friends/colleagues who might be available. We do offer referral Bonus.

Thank you.

Kind Regards,

Harris Kaushik

Clinical Recruiter

Integrated Resources, Inc.

IT Life Sciences Allied Healthcare CRO

DIRECT # - (650)-399-0891

Gold Seal JCAHO Certified ™ for Health Care Staffing

“INC 5000’s FASTEST GROWING, PRIVATELY HELD COMPANIES” (8th Year in a Row)