Job Overview
Job Description:
Provides superior customer service to all inquiries and questions regarding pre-authorization for members, providers, facilities, vendors, and other departments and teams. Uses data and process to identify members in need of Care Management and takes the appropriate action to engage the member in our Care Management or Specialty Programs with addition responsibilities in complex models of care. Acts as a trainer and mentor to new caregivers and assists in onboarding activities and ongoing support.
Job Essentials
1. Takes a lead role in department sponsored project teams to develop and implement new programs or process improvement initiatives.
2. Supports Utilization Review with more complex authorizations for medical or behavioral health treatment.
3. Receives incoming calls from members, providers, facilities, vendors, and other departments while providing professional solutions and information for situations and problems. Follows established guidelines to complete pre-authorizations for members and providers.
4. Supports care management programs over multiple disciplines by calling members and offering information/resources or engagement in Care Management, starting cases and tasking cases to the Care Manager.
5. May work in a specialty program i.e. Restricted, Healthy Beginnings, Behavioral Health etc. using reports, specialized interactions or work assigned appropriate to a Level III.
6. Completes report assignments in designated time frames. Reviews inpatient facility census and makes referrals to Care Manager as appropriate .
7. Makes outbound calls as needed to obtain information for compliance with NCQA guidelines, CMS or other regulatory guidelines for completion of utilization review pre-authorizations in a timely manner. Notifies requesting providers of review outcome.
8. Complies with established auditing criteria for calls and pre-authorizations. Stays current and conversant on customer service call audit criteria as well as preauthorization and care management guidelines to provide accurate information and NCQA compliant service.
9. Coordinates member needs with other SelectHealth departments.
10. May index and distribute inbound requests from AWD and other documentation systems to appropriate team members in a timely fashion. Indexes and distributes cases to medical reviewers.
Minimum Qualifications
One year of experience as an Intake Coordinator II.
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Demonstrated proficient knowledge of CareRadius, ICentra, Facets, and other required systems.
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Cross trained in at least two different skills within Health Services i.e. Medical/Behavioral Health, Healthy Beginnings, Benefit Determination, AWD, Line of Business (LOB) and specialized LOB programs including the Medicaid Restriction program and Medicare Advantage Duals program.
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Meets minimum quality and performance standards for a consecutive 6 month period prior transitioning to a Level II.
Preferred Qualifications
Knowledge of medical terminology or medical background.
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Ability to work independently, demonstrates flexibility, and be self-motivated with a positive attitude.
Physical Requirements:
Interact with others requiring the employee to communicate information.
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Operate computers and other office equipment requiring the ability to move fingers and hands.
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See and read computer monitors and documents.
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Remain sitting or standing for long periods of time to perform work on a computer, telephone, or other equipment.
Location:
SelectHealth – Murray
Work City:
Murray
Work State:
Utah
Scheduled Weekly Hours:
40
