Care Review Processor I

Job Title

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

Day to Day

Job Duties:

• Answering calls on a phone queue
• Sending out provider requests to nursing staff
• Answering provider questions
• Scheduling Peer 2 Peer requests

Top

Skills Required:

• Some knowledge of healthcare
• Previous phone queue experience
• Fast learner
• Able to work independently
• Previous remote working experience
• Knowledge of Microsoft office products

Required Education/Certification(s):
High school diploma, Medical Assistant if possible

Required Years of

Experience:

1-2 years

Essential Functions:

• Provide computer entries of authorization request/provider inquiries by phone, mail, or fax.
• Verify member eligibility and benefits
• Determine provider contracting status and appropriateness
• Determine diagnosis and treatment request
• Assign billing codes (ICD-9/ICD-10 and/or CPT/HCPC codes)
• Determine COB status
• Verify inpatient hospital census-admits and discharges
• 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 Client operational time frames
• Participates in interdepartmental integration and collaboration to enhance the continuity of care for Client 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
  *** policy
• Follow Standards of Conduct guidelines as described in
  *** 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
• Computer skills and experienced user of Microsoft Office software
• Accurate data entry at 40 WPM minimum

Required

Education:

High School Diploma/GED

Required Experience:

0-2 years of experience in a Utilization Review Department in a Managed Care Environment. Previous Hospital or Healthcare clerical, audit or billing experience. Experience with Medical Terminology.