Associate Care Management Coordinator

Highmark Health

2d•$19 - $27•Onsite

About The Position

JOB SUMMARY Perform accurate and timely processing of pre-certification requests for authorization of medically necessary health care services at the appropriate level of care, based on the benefits for the line of business, and in compliance with the organization's policies, procedures and regulatory requirements. Document, process and route requests for services to the nurse reviewer and other departments based on documentation procedures, including review type, clinical information, and decision timeframes. Follow policies and procedures to assure case completion and compliance with state and federal regulatory agencies. Maintain or exceed department standards for call volume, response time and related production and quality measures. May interact with other departments and providers to resolve cases. ESSENTIAL RESPONSIBILITIES: Communicate effectively Proactively inform designated individuals of the status of work assignment to assure decision timeframes and notification requirements are met Communicate effectively with Utilization Management Staff, providers, other internal and external customers and management Route Cases Based on Established Guidelines Provide accurate and timely routing of service requests to the nurse reviewer to assure that the decision and notification timeframes are in compliance with regulatory guidelines Process service requests meeting established guidelines, and document and route requests that are not permitted Request additional information verbally and in writing when the information provided is not adequate to make a medical necessity determination Maintain or exceed department call center standards Adhere to line of business phone standards to assure regulatory requirements are met Utilize phone functions to monitor the number of calls in queue and wait time Utilize daily phone standard reports to assess opportunities for self improvement Meet or exceed standards for other production and quality measures Other duties as assigned or requested.

Requirements

High School Diploma / GED
Experience in customer service
Experience in typing, keyboard and computer skills
Work experience in medical terminology

Nice To Haves

Associates degree or certification in a health related occupation
Work experience with ICD-9 and/or CPT coding

Responsibilities

Communicate effectively
Proactively inform designated individuals of the status of work assignment to assure decision timeframes and notification requirements are met
Communicate effectively with Utilization Management Staff, providers, other internal and external customers and management
Route Cases Based on Established Guidelines
Provide accurate and timely routing of service requests to the nurse reviewer to assure that the decision and notification timeframes are in compliance with regulatory guidelines
Process service requests meeting established guidelines, and document and route requests that are not permitted
Request additional information verbally and in writing when the information provided is not adequate to make a medical necessity determination
Maintain or exceed department call center standards
Adhere to line of business phone standards to assure regulatory requirements are met
Utilize phone functions to monitor the number of calls in queue and wait time
Utilize daily phone standard reports to assess opportunities for self improvement
Meet or exceed standards for other production and quality measures
Other duties as assigned or requested.