· Responsible for coordinating cases for precertification and prior authorization review.
MAJOR JOB DUTIES AND RESPONSIBILITIES: Primary duties may includes, but are not limited:
· Managing incoming calls or incoming post services claims work.
· Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.
· Refers cases requiring clinical review to a Nurse reviewer.
· Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.
· Responds to telephone and written inquiries from clients, providers and in-house departments.
· Conducts clinical screening process.
· Authorizes initial set of sessions to provider.
· Checks benefits for facility based treatment.
· Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.
· Requires High school diploma
· 1 year of customer service or call-center experience; proficient analytical, written and oral communication skills; or any combination of education and experience, which would provide an equivalent background.
· Medical terminology training and experience in medical or insurance field preferred.