About the Role:

This position supports the Health Services and Utilization Management functions by acting as a liaison between Members, Physicians, Delegates, Operational Business members, and Member Service Coordinators.

Responsibilities:

• Perform review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients.
• Handle initial screening for pre-certification requests from physicians/members via incoming calls or correspondence based on scripts and workflows, and under the oversight of clinical staff.
• Prepare, document, and route cases in the appropriate system for clinical review.
• Initiate call backs and correspondence to members and providers to coordinate and clarify benefits.
• Upon completion of inquiries, initiate call back or correspondence to Physicians/Members to coordinate/clarify case completion.
• Review professional medical/claim policy related issues or claims in pending status.
• Authorize services based upon scripts or algorithms used for pre-review screening upon collection of clinical and non-clinical information.Non Clinical staff members are not responsible for conducting any UM review activities that require interpretation of clinical information.
• Perform other relevant tasks as assigned by Management.

Education Qualification:

• High School Diploma required. Some College preferred.

Required Skills:

• Knowledge of medical terminology.
• Good Oral and Written Communication skills.
• Ability to make sound decisions under the direction of Supervisor.
• Knowledge of contracts, enrollment, billing & claims coding/processing preferred.
• Knowledge of Managed Care principles preferred.
• Ability to analyze and resolve problems with minimal supervision.
• Ability to use a personal computer and applicable software and systems.
• Team Player with strong Analytical and Interpersonal Skills.