Qualifications

• High school education or equivalent and/or two years’ experience in health insurance environment.
• Experience in Utilization or Case Management Department interacting with clinical staff.
• Good understanding of health benefits claims processing, knowledge and understanding of current procedural terminology (CPT), healthcare common procedure coding system (HCPCS) and international classification of diseases (ICD) 9/10 codes preferred.
• Good understanding of generally accepted medical practices and knowledge of state and Employee Retirement Income Security Act (ERISA) mandated benefits, plan language and contracts preferred.
• Good knowledge of medical terminology, hospital, clinic or laboratory procedures preferred.
• Proficient in Microsoft Office (Word, Excel, Outlook) and electronic health record software.
• Detail oriented with strong analytical skills.
• Motivated self-starter with the ability to work independently, as well as, part of a team.
• Excellent verbal and written communication skills.
• Proficiency in both English and Spanish is required.
• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.
• Home router with wired Ethernet (wireless connections and hotspots are not permitted).
• A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
• A functioning smoke detector, fire extinguisher, and first aid kit on site.

Duties And Responsibilities

• Review all utilization requests and forward, research, and analyze to determine if clinical or administrative in nature. Forward clinical issues to the appropriate staff for processing and handle administrative issues as appropriate.
• Enter accurate and complete authorization information into the system. Generate member and provider approval letters, as appropriate.
• Clarify CPT, HCPCS, and ICD-10 codes with conflicting, missing, or unclear information by consulting with provider’s staff. Maintain positive relationships with provider offices.
• Determine the eligibility of the member and resolve questionable eligibility with Administration department, as appropriate.
• Transmit correspondence or medical records by mail, e-mail, or fax.
• Assess network status of requested providers. If non-network, determine if alternate network providers are available to provide same service. Communicate non-network status to requesting provider and ensure member is aware of same.
• Protect the security of medical records to ensure that confidentiality is maintained.

• Work with Claims, Customer Service, Provider Maintenance and Contracting staff to provide complete information necessary for clinical review.
• Complete letter of agreement (LOA) requests for medically necessary services as needed. Follow up with Contracting Department for results on negotiations.
• Ensure providers and members are notified and document when out of network services have been requested.
• Operate the telephone queue according to department benchmarks and break schedules.
• Maintain professional telephone etiquette demonstrating patience and willingness to assist callers.
• Maintain records of all patient related phone conversations in the authorization system.
• Scan, enter, and approve retrospective authorization requests and claims as directed by clinical staff.
• Ensure retrospective claims are not duplicates by researching in claims system.
• Utilize clinical staff for concerns and questions regarding processing of retrospective requests.
• Adhere to desktop procedure for managing retrospective requests and get authorization for J-codes prior to processing.
• Schedule meetings for participants with the HM team.

• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, be self-accountable, create a positive impact, and be diligent in delivering results.

• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).
• All other duties as assigned.

Physical Demands/Work Environment