Job Description
o Screen incoming calls and / or faxes or other digital format for UM and / or CM and direct calls / faxes / other digital requests to the appropriate area.
Identify and refer cases appropriately to the Case Management and / or Transition of Care department.
o Receiving, investigating and resolving customer inquiries and claims. Maintain departmental goals. Perform projects, review and handle reports as assigned.
o Load complete organization determination / notification for services designed by internal policy. Clearly document and key data in to the appropriate system using departmental guidelines.
o Interact with membership, hospital and provider staff, advising of UM decision, status organization determinations, giving direction as necessary.
o Search for and key appropriate diagnosis and / or procedure code as part of the notification / prior authorization process.
o Must be able to pass required testing.
o Participation and attendance are mandatory.
o This position requires flexibility, due to rotations in schedules, and requires adherence to assigned schedules.
o Work overtime as required
Quals
All applicants will be advised that Client, as a federal contractor, may be required to implement a COVID- vaccine mandate.
Job Qualifications
o High School Diploma or equivalent
Experience
o year - Customer service experience is required
Skills Certifications
o Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
o Proficient oral and written communication skills
o Proficient interpersonal and organizational skills
o Exceptional time management skills
o Ability to work independently under general supervision and collaboratively as part of a team in a fast paced environment
o Independent, Sound decision-making and problem-solving skills
o If current employee with the company, must meet minimum performance expectations
o Extensive knowledge of all aspects of Utilization Management, Care Management, and Behavioral Health.
o Knowledge and understanding of Medical terminology
o Solid knowledge and understanding of provider reimbursement methodologies, ICD CM, CPT, HCPCS and UB- coding, UHDDS coding guidelines, AHA Coding Clinic
o Ability to talk and type simultaneously in a clear and concise manner while interacting with customers
EEO :
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