ECS Clinical Coverage Review / Prior Auth

Purpose of Job: Positions in this function are responsible to determine if prior authorization is required and can be decisioned, or if it requires additional clinical review. Individuals support clinicians by contacting health providers and/or members to verify authorization or referral, setup cases, and document findings. Positions in this function includes those responsible for initial triage of members, administrative intake of members and working with hospitals and the clinical team. 

Primary Responsibilities:

• This is a production role and you will have the responsibility to meet production, quality and regulatory expectations
• Ensure case is set up correctly and document required information
• Review, research and determine if case can be decisioned or if it requires additional clinical review
• Demonstrate proficiency and decision making by solving complex problems using available resources (documents, medical policy, standard operating procedure, etc.)
• As needed, make outbound calls to providers and/or members to obtain information regarding a case
• As needed, make outbound calls to providers to coordinate provider availability in treating members
• Other duties as assigned by manager and/or director

Qualifications

Required:

• Minimum of a High School Diploma / GED
• 1 years of professional experience in an office or healthcare environment
• Prior customer service experience making outbound calls
• Proficiency in using a computer
• Experience working with Microsoft Office Products including Microsoft Outlook (ability to create, edit, save, and send emails), Microsoft Word (ability to create, edit, save, and send documents), and Microsoft Excel (ability to create, edit, save, and send spreadsheets)
• Ability to work an eight (8) hour shift Monday-Friday between 7am-7pm; Tuesday-Saturday or Sunday-Thursday shifts may be available
• Flexibility to work outside standard hours of operations due to changing business needs
• Ability to trouble shoot and setup computer equipment independently
• Must have a designated work area established that is separate from other living areas and can be secured to maintain PHI or PI security in line with UnitedHealth Group policies and standards
• Remote but MUST live in a location that can receive a dedicated hard-wired high-speed internet connection or leverage an existing high-speed internet service provider (ISP) (minimum speed 1.5 download mps and 1 upload mps). In areas where a UnitedHealth Group approved ISP is not available, manager approval to leverage a local ISP and receive reimbursement for business utilization is required and available on exception basis only

Preferred:

• Previous experience working with back office medical platforms and/or authorizations systems
• Experience working within the Healthcare Industry, Hospital, Physician's Office, or Medical Clinical setting, Medical Terminology, ICD-10 and CPT codes, Medicare and/or Medicaid Services
• Professional experience in a Clerical or Administrative support related role
• Able to quickly learn various computer systems or applications

Soft Skills:

• Strong communication skills; Written and verbal
• Excellent critical thinking and problem - solving skills
• Candidate needs to be highly organized
• Analytical, problem solving and decision-making skills; ability to exercise good judgment