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:

Associate (Preferred)

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

CO jobs

Care Review Processor