Care Review Processor

Care Review Processor I

Location:

Fully Remote Work Authorization:
Must reside in an approved work state and be available to work Eastern Time (ET) hours.

• 9:30 AM – 6:00 PM ET, or
• 10:30 AM – 7:00 PM ET

• Dual monitors
• Docking station
• Standard laptop, headset, keyboard, and mouse

The Care Access & Monitoring (CAM) Coordinator provides clerical, administrative, and data entry support for members requiring hospitalization and/or utilization review for healthcare services. This role is responsible for verifying eligibility and benefits, processing authorization requests, entering and maintaining data, and coordinating information with healthcare services staff to support the delivery of high-quality, cost-effective healthcare services while complying with federal and state regulations.

• Process incoming faxes and documentation.
• Create and process authorization requests.
• Handle inbound and outbound phone calls.
• Verify member eligibility and benefits.
• Review provider participation and appropriateness.
• Process diagnosis and treatment requests.
• Assign and review ICD-9, ICD-10, CPT, and HCPCS codes.
• Determine Coordination of Benefits (COB) status.
• Verify inpatient admissions, discharges, and hospital census information.
• Enter and maintain accurate data within designated systems and databases.
• Follow established protocols and workflows.
• Contact physician offices to obtain missing information and supporting documentation.
• Notify nurses and case managers of admissions and changes in member status.
• Maintain accurate records and meet productivity standards.

• Respond to authorization requests received via phone, fax, and mail within established service-level time frames.
• Collaborate with interdisciplinary teams, including Behavioral Health and Long-Term Care, to support continuity of care.
• Provide excellent customer service to internal and external stakeholders.
• Participate in quality assurance activities, audits, and Inter-Rater Reliability (IRR) reviews.
• Maintain compliance with HIPAA regulations and confidentiality standards.
• Participate in department meetings and team initiatives.
• Adhere to attendance, workplace safety, and company conduct policies.
• Meet departmental productivity and quality expectations.

• High School Diploma or GED required.

• 0-2 years of experience in a Utilization Review or Managed Care environment.
• Previous healthcare, hospital, medical office, billing, audit, or clerical experience preferred.
• Experience with medical terminology required.

• Utilization Management (UM) and/or health insurance experience.
• Experience working in a medical office, hospital, healthcare, or managed care setting.
• Working knowledge of medical terminology and abbreviations.
• Strong data entry skills with a minimum typing speed of 40 WPM.
• Proficiency with Microsoft Office applications.
• Strong analytical, problem-solving, and organizational skills.
• Excellent verbal and written communication skills.
• Ability to work independently and as part of a team.
• Ability to manage confidential information appropriately.
• Ability to thrive in a fast-paced environment.

• Fully remote position.
• Access to protected health information (PHI) required.
• Network access required.
• Supports Medicaid and multiple health plan lines of business.
• Standard administrative duties include authorization processing, fax management, and provider/member communications.

The ideal candidate will have experience in Utilization Management, health insurance operations, claims processing, authorizations, eligibility verification, or healthcare administration and will be comfortable handling high-volume administrative work in a remote environment while delivering exceptional customer service.