Medical Management Coordinator - Jefferson Health Plan

Thomas Jefferson University • Philadelphia, PA

2d • Onsite

About The Position

Works under general supervision to collect and process information for inpatient and outpatient authorization requests through the Medical Management system, provider portal, and call center. The coordinator facilitates authorizations through technical authorization and payment processes and supports clinical case managers, providers, members, and internal teams.

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 manage multiple responsibilities simultaneously.
• Excellent telephone, 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 status, and update the system and authorization.
• Manage authorizations submitted through the provider portal via the 278 transaction, and verify required fields before assigning cases to the appropriate case manager.
• Process all cases assigned by leadership.
• Monitor and prepare clinical information and 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 call center service and maintain call service thresholds.
• Verify member eligibility using internal systems 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 to outstanding claims issues raised through provider inquiries or written requests.
• Assist member and provider services with authorization questions and general customer service for internal and external customers.
• Support clinical case managers by closing cases when applicable.
• Maintain established phone-service key indicator thresholds.
• 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 or data integrity.

Benefits

• Medical insurance, including prescription coverage
• Supplemental insurance
• Dental insurance
• Vision insurance
• Life and AD&D insurance
• Short- and long-term disability
• 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
• Medical insurance, including prescription coverage, is available to all colleagues, including those working less than part-time

What This Job Offers

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