Care Review Processor With Utilization Review/Managed Care Exp. (Remote - Ca)

Care ReviewProcessor with Utilization Review/ManagedCare Exp. (REMOTE - CA)

We are looking to hire a candidate with the experience and skill sets mentioned for one of our major clients within the Health Insurance industry. This is a REMOTE role. This is a 6-month contract opportunity with the possibility of extensions.

*This position is fully remote. However, candidates MUST reside in California (CA).

Job Summary:

This position will support both the ECM/CS teams as needed with a focus on Community Support.  The position will be meeting with providers and guiding internal teams on how to submit for prior authorizations for community support.  Answering questions internal and external for providers, as well as processing prior authorizations for ECM services. Need to have experience and knowledge of MEDI-CAL.

Works within the Care Access and Monitoring (CAM) team to provide clerical and data entry support for Molina Members who require hospitalization and/or utilization review for other healthcare services. Checks eligibility and verifies benefits, obtains and enters data into systems, processes requests, and triages members and information to the appropriate Health Care Services staff to ensure the delivery of high quality, cost-effective healthcare services according to State and Federal requirements to achieve optimal outcomes for Molina Members.

Position Responsibilities:

• Provide computer entries of authorization requests/provider inquiries by phone, mail, or fax. Including:
  • Verify member eligibility and benefits.
  • Determine provider contracting status and appropriateness.
  • Determine diagnosis and treatment requests.
  • Assign billing codes (ICD-9/ICD-10 and/or CPT/HCPC codes).
  • Determine COB status.
  • Verify inpatient hospital census admits and discharges.
  • Perform the 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 Molina operational timeframes.
• Participates in interdepartmental integration and collaboration to enhance the continuity of care for Molina 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 monitor nurses and case managers of hospital admissions and changes in member status.
• Meet productivity standards.
• Maintain confidentiality and comply with the 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 Molina Healthcare policy.
• Follow Standards of Conduct guidelines as described in Molina Healthcare HR policy.
• Comply with required workplace safety standards.

Required Skills/Experience/Education:

• 2+ years of experience in a Utilization Review Department in a Managed Care Environment. Previous Hospital or Healthcare clerical, audit, or billing experience.
• 2-3+ years for prior authorization process for UM/CM.
• Experience processing prior authorizations for ECM services.
• Prefer 1 year in ECM/CS.
• Need to have experience and knowledge of MEDI-CAL.
• Candidates with Prior authorization processing for ECM/CS/provider relations/provider and internal education are Highly Preferred.
• Experience with Medical Terminology and abbreviations.
• Computer skills and experienced user of Microsoft Office software.
• Accurate data entry at 40 WPM minimum.
• Demonstrated ability to communicate, problem-solve, and work effectively with people.
• 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.
• High School Diploma/GED.

Other job specifications:

• Employment Type: Contract to Hire (CTH), W2 only. NO C2C.
• Contracting Period: 6-month contracting opportunity with the possibility of extensions.
• Job Location: This position is fully remote. However, candidates MUST reside in California (CA).
• Contract Rate: $20/hr. on W2.
• Interview Process: 1-Interview (Microsoft Teams Meeting).