WCM/CCM EC/Precert Specialist

WCM/CCM EC/Precert Specialist

Anticipated work hours are between 8:00a.m. - 6:00 p.m. (overtime is not required; weekends are expected and include every Saturday on rotation). Remote

Required Skills and Experience:

Medical Terminology or medical background such as nursing assistant/tech or doctor office experience Customer Service experience

Exceptional phone skills

Administrative/PC skills

Highly preferred:

- Triage and resolve inquiries via calls, voicemail messages, electronic systems, or faxes, that are

received from internal and external stakeholders for precertification and appeals.

- Refer and/or warm transfer to wellness and care management components and other BCBSM areas and vendors as needed

1.. Perform non-clinical authorizations and letter generation according to the department guidelines.

2. Evaluate and identify clinical requests that require medical necessity review and route to

appropriate clinical staff.

3. Receive medical records, evaluate and prepare cases for clinical review, including determining

group-specific requirements, type of admission, level of review and ensure regulatory timeframes

are met.

Ability to function independently.

Critical Thinking

Quick learner

EDUCATION AND/OR EXPERIENCE

1. Two (2) years of college is preferred.

2. Experience with benefits and procedures as related to assigned

department.

3. Three (3) to five (5) years of experience in the healthcare industry preferred.