About the position
The position involves assessing the need for health care resources and insurance, obtaining detailed benefit coverage for specified plan members, and checking eligibility status. The role requires investigating and following up on all eligibility issues in accordance with health plan and SRS guidelines. The candidate will also provide department support by maintaining and organizing data, preparing and distributing reports within designated timeframes, and managing correspondence to members, PCPs, health plans, and other service providers. Additionally, the role includes making phone calls to assist in care coordination under the guidance of case managers, organizing and maintaining case files, and contributing to continuous improvement initiatives of the Case Management team to deliver quality interventions timely.
Responsibilities
- Assess the need for health care resources and insurance.
- Obtain detailed benefit coverage for specified plan members.
- Check eligibility status.
- Investigate and follow-up on all eligibility issues in accordance with health plan and SRS guidelines.
- Maintain and organize data, prepare and distribute reports within designated timeframe.
- Manage correspondence to members and PCP, health plans, and other service providers.
- Make phone calls to members, physician offices, health plans, and providers to assist in care coordination under the guidance of case managers.
- Organize and maintain case files.
- Provide clerical support and assistance to the Case Management team.
- Contribute to continuous improvement initiatives of the Case Management team.
- Maintain data, run reports in an organized and timely manner.
- Organize and implement daily work plan for designated facility.
- Obtain detailed benefit coverage for complex requests for service specific to member plan coverage.
- Apply principles of medical group guidelines and Health Plan benefit guidelines to approve referrals.
- Investigate and follow-up on all eligibility issues.
- Classify patients into full risk/shared risk grouping according to the Division of Financial Risk.
- Identify 'Third Party Liability' (TPL) cases and process referrals for prior authorization.
- Responsible for submission of electronic Prior Auth referrals.
- Gather necessary medical information for use by Medical Directors, Hospitalist Physician, and/or Case Manager.
- Research and assist in the denial and appeal process.
- Gather clinical information from multiple sources for review by Case Managers.
- Verify and document eligibility and benefit details.
- Apply specific health plan criteria and/or guidelines to all prior authorization requests.
Requirements
- Successful completion of ICD and CPT coding classes, or equivalent work experience.
- 3 years working in the managed health care field, preferably HMO or delegated risk medical group/IPA setting.
- 1 year experience with medical coding and data entry, preferably in a managed care environment.
Nice-to-haves
- Successful completion of Medical Assistant Program or equivalent.
Benefits
- 401k
- health insurance
- paid holidays
- professional development
