Care Management Coordinator (Remote)

Highmark Health • DE, Working at Home - Delaware, DE

16h • $22 - $33 • Remote

About The Position

This job performs 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. Documents, processes and routes requests for services to the nurse reviewer and other departments based on documentation procedures, including review type, clinical information, and decision timeframes. Follows policies and procedures to assure case completion and compliance with state and federal regulatory agencies. Maintains or exceeds department standards for call volume, response time and related production and quality measures. May interact with other departments and providers to resolve cases.

Requirements

• 3 years of experience in customer service
• 3 years of experience in typing, keyboard and computer skills
• 3 years of work experience in medical terminology
• Compliance with all regulatory agency requirements is essential as consequences could result in potential for sanctions up to possible contract termination for all product lines
• High School diploma / GED

Nice To Haves

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

Responsibilities

• 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.
• 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.
• Escalate appropriate cases to leadership that require a clinical review and/or other intervention.
• Assist with reporting as directed.
• Participate in precepting of new employees, as assigned.
• 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.

Benefits

• Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED