PURPOSE:

Supports the Utilization Management clinical teams by assisting with non-clinical administrative tasks and responsibilities related to pre-service, utilization review, care coordination and quality of care.

ESSENTIAL FUNCTIONS:

• 35% Performs member or provider related administrative support which may include benefit verification, authorization creation and management, claims inquiries and case documentation.
• 35% Reviews authorization requests for initial determination and/or triages for clinical review and resolution.
• 20% Provides general support and coordination services for the department including but not limited to answering and responding to telephone calls, taking messages, letters and correspondence, researching information and assisting in solving problems.
• 10% Assists with reporting, data tracking, gathering, organization and dissemination of information such as Continuity of Care process and tracking of Peer to Peer reviews.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education Level: High School Diploma

Experience: 3 years experience in health care claims/service areas or office support.

Preferred Qualifications

• Two years' experience in health care/managed care setting or previous work experience within division
• Knowledge of CPT and ICD-10 coding.

Knowledge, Skills and Abilities (KSAs)

• Ability to effectively participate in a multi-disciplinary team including internal and external participants., Proficient
• Excellent communication, organizational and customer service skills. , Proficient
• Knowledge of basic medical terminology and concepts used in managed care., Proficient
• Knowledge of standardized processes and procedures for evaluating medical support operations business practices., Proficient
• Excellent independent judgment and decision-making skills, consistently demonstrating tact and diplomacy. , Proficient
• Ability to pay attention to the minute details of a project or task, Proficient
• Experienced in the use of web-based technology and Microsoft Office applications such as Word, Excel, and Power Point, Proficient

Top 5 Required Skills:

• Medical back ground, computer skills, medical terminology, claims and service office support, CPT and ICD-10 coding