Health Services Assistant-ABQ

Presbyterian Healthcare Services•New York, NY

5d•$17 - $29•Onsite

About The Position

Responsible for supporting Health Services Coordination functions including, but not limited to, medical records coordination, technical retrospective claims review, referral/auth. entry, research which may include but not limited to claims, eligibility, benefits, provider contracts, coordination of benefits, provider education, data entry report generation, act as liaison to and/or assists PHS clinical leaders.

Requirements

High School Diploma or GED required.
One to three years' experience in a medical or health insurance position.

Nice To Haves

Associates Degree or completion of a medical vocational program preferred.

Responsibilities

Process emergent/elective and transitional prior authorization requests according to established evidenced based criteria.
Screen prior authorization requests not meeting guidelines and request/gather/forward additional information.
Conduct utilization review by monitoring daily prior authorization requests and documenting timely updates for service requests.
Complete Administrative Denials and submit Medical Director Reviews as directed.
Notify members and providers including but not limited to approvals, provider notification of service requests and out of network approvals.
Monitor benefit limitations for all members.
Identify members for case management or needed follow up regarding subrogation or coordination of benefits.
Refer to appropriate departments as needed.
Provide claims follow up as indicated.
Document in multiple computer applications timely and according to unit policy and regulations.
Document appropriate codes and claims payment information to ensure accurate claims payment.
Perform data entry to ensure accurate records notifications/referrals.
Submit Patient referrals for complaints and compliments.
Liaise with providers and facilities telephonically, including problem-solving regarding member needs.
Request clinical updates.
Respond to incoming calls routed through skill-based technology to meet quality standards and performance measurements.
Conduct outbound calls as required and meet established quality/quantity guidelines supporting initiatives and/or programs.