Job Qualifications
Education
o High School Diploma or equivalent
Experience
o 1 year - Customer service experience is required
Skills\Certifications
o Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
o Proficient oral and written communication skills
o Proficient interpersonal and organizational skills
o Exceptional time management skills
o Ability to work independently under general supervision and collaboratively as part of a team in a fast paced environment
o Independent, Sound decision-making and problem-solving skills
o If current employee with the company, must meet minimum performance expectations
o Extensive knowledge of all aspects of Utilization Management, Care Management, and Behavioral Health.
o Knowledge and understanding of Medical terminology
o Solid knowledge and understanding of provider reimbursement methodologies, ICD-9-CM, CPT, HCPCS and UB-92 coding, UHDDS coding guidelines, AHA Coding Clinic
o Ability to talk and type simultaneously in a clear and concise manner while interacting with customers
Responsibilities:
Job Profile Summary
Supports customer service activities and initiatives for a number of products or clients including but not limited to the Case Management and Utilization Management departments.
Job Description
Job Responsibilities
o Screen incoming calls and/or faxes or other digital format for UM and/or CM and direct calls/faxes/other digital requests to the appropriate area. Identify and refer cases appropriately to the Case Management and/or Transition of Care department.
o Receiving, investigating and resolving customer inquiries and claims. Maintain departmental goals. Perform projects, review and handle reports as assigned.
o Load complete organization determination/notification for services designed by internal policy. Clearly document and key data into the appropriate system using departmental guidelines.
o Interact with membership, hospital and provider staff, advising of UM decision, status organization determinations, giving direction as necessary.
o Search for and key appropriate diagnosis and /or procedure code as part of the notification /prior authorization process.
o Must be able to pass required testing.
o Participation and attendance are mandatory.
o This position requires flexibility, due to rotations in schedules, and requires adherence to assigned schedules.
o Work overtime as required
Comments/Special Instructions
Appeals and/or Grievance Preferred.
Experience with Dual - SNP plans preferred.