Job Description
You will need to go to Newark NJ to pick up equipment and some training one day, then remote for full assignment
This position supports the Health Services and Utilization Management functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators.
Responsibilities: - Performs review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients. - Handles 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 appropriate system for clinical review. - Initiates 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. - Reviewing professional medical/claim policy related issues or claims in pending status. - Upon collection of clinical and non-clinical information MCC can authorize services based upon scripts or algorithms used for pre-review screening. *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. Core Individual Contributor Competencies: Personal and professional attributes that are critical to successful performance for Individual Contributors: Customer Focus Accountable Learn Communicate Qualifications: Education: - High School Diploma required. Some College preferred.
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