Medical Management Coordinator - Jefferson Health Plan

Jefferson Health Plans • Philadelphia, PA

3d • Onsite

About The Position

Works under general supervision to collect and process information related to inpatient and outpatient authorization requests through the Medical Management system, provider portal, and call center. The coordinator also facilitates authorizations through the technical authorization and payment cycles.

The role processes and creates authorization requests, supports case managers, monitors clinical information and provider-portal activity, and helps resolve authorization and claims issues. It provides prompt telephone service to members and providers and helps maintain accurate records, coding, and data integrity.

Requirements

• High school diploma or GED.
• Two years of healthcare experience.
• Proficiency with Microsoft Office, including Word, PowerPoint, and Excel.
• Knowledge of medical terminology, utilization review systems, hospital admission systems, healthcare claims, or medical office administration.
• Ability to work and communicate effectively with coworkers, members, and providers at the owner institutions.
• Ability to work independently and as part of a team.
• Ability to work on detailed reports.
• Excellent organizational skills and ability to handle multiple responsibilities concurrently.
• Excellent telephone and verbal and written communication skills.

Responsibilities

• Follow company and department policies and procedures.
• Process and create authorization requests for emergency and elective inpatient admissions, outpatient services in medical and home settings, durable medical equipment, and urgent maternity and newborn delivery admissions according to departmental guidelines.
• Identify duplicate services and communicate them to appropriate team members.
• Follow up on outstanding prior authorizations, confirm their status, and update the system and authorization.
• Manage provider-portal authorizations submitted through the 278 transaction, verify required fields, and reassign cases to the appropriate case manager.
• Process cases assigned by leadership.
• Monitor and prepare clinical information and maintain records for submission to the Quality Improvement Organization (QIO).
• Create cases for non-participating providers using a temporary provider ID, collect provider information, and refer cases to Network Management for completion of setup needed for claims payment.
• Monitor the provider portal for failed and duplicate authorizations and support provider re-education.
• Provide prompt, courteous, continuous call-center telephone service and maintain department call-service thresholds.
• Verify member eligibility using internal systems and/or the DHS terminal and alert case managers to eligibility changes.
• Code services accurately using ICD-10, CPT, and HCPCS coding systems.
• Reconcile claim discrepancies through service forms within the three-business-day Service Level Agreement.
• Identify resolutions for outstanding claims issues raised through provider inquiries or written requests.
• Assist member services and provider services with authorization questions and general customer service for internal and external customers.
• Support Clinical Case Managers by closing cases when applicable.
• Triage medical-management clinical faxes for timely medical-necessity review and attach faxes to member cases in the Medical Management system.
• Work with the Applications Systems Management team to identify system failures affecting claim payment and data integrity.

Benefits

• Medical insurance, including prescription coverage
• Supplemental insurance
• Dental insurance
• Vision insurance
• Life and accidental death and dismemberment insurance
• Short- and long-term disability coverage
• Flexible spending accounts
• Retirement plans
• Tuition assistance
• Voluntary benefits, including access to group insurance rates and discounts
• Tuition discounts at Thomas Jefferson University after one year of full-time service or two years of part-time service
• Access to medical insurance, including prescription coverage, for all colleagues, including per-diem colleagues, adjunct faculty, and Jeff Temps

What This Job Offers

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