Durable Medical Equipment Coordinator - 24-04

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At Hill Physicians Medical Group, we're shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.
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Hill Physicians has much to offer prospective employees. We're regularly recognized as one of the "Best Places to Work in the Bay Area" and have been recognized as one of the "Healthiest Places to Work in the Bay Area." When you join our team, you're making a great choice for your professional career and your personal satisfaction.
DE&I Statement:
At PriMed, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.
We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!
Job Description:
Responsible for reviewing, researching, processing and modifying authorization requests for Durable Medical Equipment (DME), orthotic/prosthetic (O&P) devices, and medical supplies, utilizing benefit structure and appropriate vendors, according to CMS, DMHC, Health Plans and Hill Physicians guidelines. Responsible for reviewing, researching, processing and modifying authorization requests for Home Health, Home Infusion and Hospice, utilizing benefit structure and appropriate vendors, according to CMS, DMHC, Health Plans and Hill Physicians guidelines. Responsible for benefit checks for acupuncture/chiropractic and infertility authorization requests. Resolve and respond to complex issues for members, providers, health plans and vendors by conducting detailed research and by interfacing with appropriate departments and management to ensure that the standards for authorization requests are met.
Job Responsibilities

• Review and process authorization requests generated from phone calls, facsimiles, vendors, customer service or mail requests in accordance with authorization policy and procedures.
• Use appropriate guidelines established, i.e. Medicare guidelines, Hill or Health Plan guidelines as identified in established policy and procedures.
• Clear and concise writing skills to document processes taken for each DME / O&P authorization and provide sufficient information for nurse or physician review when needed.
• Refer all customized items or atypical items to an appropriate nurse for review and assist in providing Health Plan medical necessity guidelines.
• Strong navigation experience with various Health Plan websites for benefit and medical criteria searches.
• Follow departmental, Health Plan and regulatory policies and standards.
• Identify auth requests that meet established guideline requirements and benefits that can be approved.
• Complete Denial letters for services not a covered benefit per operational guidelines.
• Communicate and provide appropriate customer service to all customers, which include but not limited to providers, Health Plans, vendors, and internal staff.
• Require medical terminology experience as well as experience with ICD-9, HCPC and CPT codes.
• Assist with operational manual documentation, guidelines and process development as it relates to DME and O&P management.
• Assist with operational manual documentation, guidelines and process development as it relates to Home Health.
• Assists Concurrent Review and Case Management in all regions with identification of contracted Home Health, Home Infusion, and Hospice agencies. Provides data entry and review of auths as needed.
• Notifies respective nurse of status and any additional information pertaining to member.
• Monitor customer service response (CSR) activity and respond appropriately, within department standards of 24 hours.
• Meet departmental productivity and quality standards.
• Complete additional duties as needed to meet business needs and compliance requirements including the following:
  
  • Verify contract status (par vs. non par) of referred to providers/vendors/agencies on authorization requests for Medicare and Medi-Cal members
  • Check exclusion lists for authorization requests for Medicare and Medi-Cal members to Non Par providers/vendors/agencies.
  • Answer calls from Customer Service through Customer Service call line as needed to provide phone coverage.

Required Experience

• Strong knowledge of medical terminology.
• Knowledge of ICD-9 and CPT, and HCPCS coding.
• Data entry and computer skills.
• Ability to work independently and as part of a team.
• Knowledge of health plan benefits.
• Excellent writing skills.
• Customer service oriented

Required Education

• Medical Assistant Certification and/or 1-3 years Healthcare experience preferred.

Pay Range
$25.97 - $29.20 hourly
Additional Information

• This is hybrid position.

Hill Physicians is an Equal Opportunity Employer