Managed Care Claims Assistant I

AmTrust Financial Services•Fresno, CA

About The Position

The Managed Care Claims Assistant I position reports directly to the Director, Managed Care. This position provides daily administrative support to professional Registered Nursing staff, increasing production in the areas of Early Intervention, Case Management, and Utilization Review. This position will assist the nursing staff with Case Management (CM) and Utilization Review (UR) clerical duties.

Requirements

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
Knowledge of medical terminology CPT and ICD codes strongly preferred.
Good typing skills, basic understanding of business technology and ability to learn new procedures quickly.
Professional telephone demeanor and good oral and written communication skills.
Ability to take direction, think critically and make decisions.
Self-organized, detail oriented and be able to multi-task and work well under pressure in a fast-paced environment.
Ability to work in a team environment.
High school diploma or equivalent required.
Computer skills required with knowledge in utilizing Outlook, Microsoft Word, Excel and other databases.

Nice To Haves

Prior medical assistant type experience and/or some knowledge of medical terminology.
Minimum 1-2 years Worker’s Compensation experience or experience in a health-related service field is helpful.
Bilingual Spanish a plus.

Responsibilities

Intake, prioritizing and timely processing of new Case Management referrals.
Monitors, collects, processes, and distributes all types of correspondence accordingly. Reports issues with incoming/outgoing correspondence immediately.
Enters/uploads reports and clear notes into the CM Software Application System.
Makes timely pertinent phone calls to obtain medical reports, treatment plan and RTW related information/reports to provide to the Case Management Nursing Staff.
Transfers any/all calls where there is clinical information being provided (or a clinically related question surfaces) to a registered nurse for response - Licensed staff are always available to assist non-clinical staff while they are attempting to obtain information.
Schedules Injured Worker appointments, as appropriate and under the direction of clinical staff.
Types injured worker appointment letters and other pertinent letters as requested by and under the oversight of a registered nurse.
Maintains ongoing non-clinical communications, collaborates with pertinent parties related to claims that are open to Case Management and to manage the Utilization Review process or for other administrative tasks as needed.
Process Utilization Review requests: performs data entry functions, reviews multiple criteria to determine eligibility of treatment requests, approves treatment requests based on authority level, refers treatment requests to a clinical resource or sends appropriate response level.
Coordinates with claim adjusters or nurses to validate claims or clinical information respectively to make decisions related to eligibility of treatment requests.
Prioritizes treatment requests based on review type and ensures jurisdictional timeframes and or department turnaround times are met.
Appropriately documents all systems to reflect critical thinking and actions taken in response to treatment requests.
Ensures the privacy and security of Protected Health Information (PHI).
Performs other administrative tasks and functionally related duties as assigned by clinical review nurses, nurse case managers or supervisor.
Makes administrative decisions only, completes appropriate actions functioning under the direction of clinical staff and the Manager, Medical Case Management and within agreed upon limitations.
Responds to general customer service questions or directs the caller to the appropriate person or department.
Training and oversight of other Medical Management Liaisons and Assistants.