DME Review Coordinator

The challenges of affordable healthcare continue to create new opportunities. Elderplan and Home First, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.

The Durable Medical Equipment (DME) Review Coordinator is expected to ensure high quality, cost-effective care, and services for Elderplan/Home First members through the processing, review, and authorization of Durable Medical Equipment. The DME Review Coordinator is responsible for making first level determinations, under the support of a Registered Nurse, utilizing Medicare’s National and Local Carrier Policy, Medicare based Interqual criteria for DME, internal Medical Policy, and physician/Medical Director support for medical necessity decisions.

The DME Review Coordinator will manage the collection of supporting medical documentation, application of criteria, manage the physician advisor review process as needed, update the outcome of the review process in EP’s case management system, and manage the member/provider notification of determination process, within CMS/DOH regulatory requirements. The position requires excellent communication, organizational skills, attention to detail, and knowledge of regulatory processes.

• High School Diploma or equivalent; college degree preferred.
• Two years prior managed care experience required.
• Prior experience in a health care setting preferred.
• Familiarity with utilization management/case management.
• Excellent customer service including written and oral communication skills for communicating with vendors and providers
• Ability to us the telephone, fax, e-mail, scanner, Microsoft Word, Excel, and capacity to learn other programs as assigned
• Good analytical abilities for problem solving
• Ability to be empathetic and understanding
• Ability to handle confidential aspects of the position
• Ability to work closely maintain collegiate relationships with different professionals as part of an interdisciplinary health care team
• Ability to prioritize tasks and meet set deadlines
• Appropriately allocate resources, maximize efficiency, and contain costs
• Ability to work independently while recognizing issues having departmental or organizational impact
• Assess members' needs and identify opportunities for recommending levels of care
• Ability to handle a high volume of outbound phone calls along with written documentation