Care Review Processor I
Remote
6+ Months
Job Description:
- Will the position be 100% remote? Yes
- Are there any specific location requirements? No
- Are there are time zone requirements? HM is in EST
- What are the must have requirements? Customer Service/Health Plan Experience/Call center/Utilization
Management
- What are the day to day responsibilities? Clerking/Building Authorizations/Making outbound calls/Taking inbound
Calls
- What is the desired work hours (i.e. 8am – 5pm) 8:30-5:00pm
Equipment will require dual monitors, docking station and hard wired head set.
Summary: Works within the Care Access and Monitoring (CAM) team to provide clerical and data entry support for
Client Members that require hospitalization and/or utilization review for other healthcare services. Checks eligibility
and verifies benefits, obtains and enters data into systems, processes requests, and triages members and information to
the appropriate Health Care Services staff to ensure the delivery of high quality, cost-effective healthcare services
according to State and Federal requirements to achieve optimal outcomes for Client Members. Essential Functions:
Provide computer entries of authorization request/provider inquiries by phone, mail, or fax. Including:
o Verify member eligibility and benefits,
o Determine provider contracting status and appropriateness,
o Determine diagnosis and treatment request
o Assign billing codes (ICD-9/ICD-10 and/or CPT/HCPC codes),
o Determine COB status,
o Verify inpatient hospital census-admits and discharges,
o Perform action required per protocol using the appropriate
Database. Respond to requests for authorization of services submitted to CAM via phone, fax and mail according to
Client operational timeframes. Participates in interdepartmental integration and collaboration to enhance the
continuity of care for Client members including Behavioral Health and Long Term Care. Contact physician offices
according to Department guidelines to request missing information from authorization requests or for additional
information as requested by the Medical Director. Provide excellent customer service for internal and external
customers. Meet department quality standards, including inter-rater reliability (IRR) testing and quality review audit
scores. Notify Care Access and Monitoring Nurses and case managers of hospital admissions and changes in member
status. Meet productivity standards. Maintain confidentiality and comply with Health Insurance Portability and
Accountability Act (HIPAA). Participate in Care Access and Monitoring meetings as an active member of the team. Meet
attendance guidelines per Client Healthcare policy. Follow Standards of Conduct guidelines as described in Client
Healthcare HR policy. Comply with required workplace safety standards. Knowledge/Skills/Abilities: Demonstrated
ability to communicate, problem solve, and work effectively with people. Working knowledge of medical terminology
and abbreviations. Ability to think analytically and to problem solve. Good communication and interpersonal/team skills.
Must have a high regard for confidential information. Ability to work in a fast paced environment. Able to work
independently and as part of a team. Computer skills and experienced user of Microsoft Office software. Accurate data
entry at 40 WPM minimum. Required Education: High School Diploma/GED
Required Experience: 0-2 years of experience in a Utilization Review Department in a Managed Care Environment.
Previous Hospital or Healthcare
clerical, audit or billing experience. Experience with Medical Terminology
Job Type: Contract
Pay: $21.00 - $22.00 per hour
Medical Specialty:
- Critical & Intensive Care
Schedule:
- 8 hour shift
- Monday to Friday
Education:
Experience:
- Utilization review: 8 years (Preferred)
- Care Access and Monitoring: 8 years (Preferred)
- ICD-9/ICD-10: 8 years (Preferred)
- CPT/HCPC codes: 6 years (Preferred)
- HIPAA: 6 years (Preferred)
- Prior Authorization: 8 years (Preferred)
Work Location: Remote