Clinical Documentation Specialist

TPIS • Guaynabo, PR

11d • Hybrid

About The Position

This is a clinical administrative support role responsible for receiving, registering, and forwarding requests for organizational determination and/or associated clinical documentation. The role works with predetermined service authorizations using benefit criteria and in compliance with applicable regulations. Strong attention to detail and a healthcare industry background are essential for this position.

Requirements

• Associate’s Degree and/or sixty to sixty-four (60-64) university credits equivalent to six (6) months to one (1) year of studies in a health-related area.
• At least one (1) year of related experience.
• Knowledge of Medical Terminology.
• Spanish Intermediate (conversational, writing, and comprehension).
• English Intermediate (conversational, writing, and comprehension).

Nice To Haves

• Knowledge of CPT and ICD-10 Codes.

Responsibilities

• Receive requests for pre-service organizational determination and/or clinical documentation for insured management via facsimile, email, regular mail, or provider portal.
• Perform Gatekeeper roles to classify documentation and distribute it to technicians.
• Check the expiration date of faxes.
• Manage and analyze received documentation, including medical orders, to establish the type of service requested and level of urgency, ensuring it meets minimum requirements.
• Perform eligibility search and pre-authorization requirement checks for requested services, validating information with the provider.
• Document pre-authorizations in the insured's file according to established requirements and regulations.
• Handle complex requests such as services in the US, durable medical equipment, and hospital discharge, requiring communication with clinical areas.
• Authorize services predetermined through the automatic process using benefit criteria, in compliance with regulations, including notification to the insured/provider.
• Monitor assigned request times to maintain compliance percentages for authorizations and area assemblies.
• Answer unit calls in compliance with HIPAA regulations and forward them to corresponding programs, including complex scenarios.
• Handle appeals requests, communicating with the Grievances and Appeals Unit and understanding appeal scenarios and their impact on STARS.
• Process queries and requests from the Call Center and Service Centers by modifying pre-authorizations or handling verbal requests.
• Inform the Providers Department of services requiring payment agreement letters for additional nonparticipating providers and coordinate provider configuration.
• Comply fully and consistently with company standards, policies, procedures, and applicable local and federal laws.

Benefits

• Benefits

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree