The Healthcare Clinical Information Associate coordinates any request that is received in the Use management Department by phone, fax or in writing to ensure provider/member authorizations/appeals are handled in accordance with contract provisions, corporate policies and regulatory guidelines. Responsibilities include review of contracted benefits and provider status with HealthNow and the Blues Network. Initial requests are reviewed for benefits, provider status and timeframes, and then the Associate is responsible to forward the case to the nurse for medical review.
Primary Job Duties:
- Review, assess and process pre-authorization/appeal requests from provider offices, members, vendors or facilities to determine the correct product and benefit available for the requested service. Respond within required time frames. Associate authorizes treatment or service as appropriate within the scope of authority.
- Determine if review would be contractual in nature. Direct to the appropriate area for intervention and resolution.
- Access various data sources for facility contracts to assist Use Management staff in determining approval of requests. Route requests to the appropriate internal staff based on the understanding and knowledge of regulatory compliance and requirements. Prepare cases for nurse review.
- Support Use Management staff and complete requests to include: responding to inquiries from providers/members and determine appropriate correspondence template to be utilized for various situations. Identify changes needed to the provider/member's files and refer to appropriate department for corrections.
- Perform advanced research to assist in determining whether or not there are participating providers who will provide a specific service being requested.
- Utilize DME SOP for pricing for Dump code if Medical Review is not required.
- Performs other related duties as required.
Associates Degree (N/A)
- Communicate effectively, both in writing and verbally to vendors, physician offices, facilities and members.
- Comprehensive knowledge of benefit practices and contract provisions.
- Understanding and maintaining of regulatory compliance and requirements.
- Ability to work in a fast paced Team environment, while also working independently and attention to detail oriented under highly regulated time frames.
- Working knowledge of personal computer and application software with basic knowledge of all applicable internal computer systems.
- Preferred knowledge and understanding of proper use of CPT procedure codes, HCPC(DME) codes and ICD (Diagnosis) codes along with medical terminology, dental terminology and coding techniques.
Health Information Tech, Medical Records, LPN or accredited comparable health related degree. 1 - 2 yrs experience Health Information or Medical Records Tech or previous experience in a medical or dental office setting. Preferred knowledge and understanding of proper use of CPT procedures codes, HCPC (DME) codes and ICD (Diagnosis) codes along with medical terminology, dental terminology and coding techniques.
Knowledge acquired through 2 - 3 yrs previous experience in a medical, dental office setting or health plan. Preferred knowledge and understanding of proper use of CPT procedures codes, HCPC (DME) codes and ICD (Diagnosis) codes along with medical terminology, dental terminology and coding techniques.
- Shift work
- Irregular hours
- Must be able to work in an office environment
- Repetitive Motion
- Prolonged Standing
- Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks
- Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc)
- Vision Req: Close vision (clear vision at 20 inches or less)
- Vision Req: Distance (clear vision at 20 feet or more)
- Physical Effort: Minimum; typical of most office work. Mostly sedentary work.
- Weight: Occasionally lift/carry under 10 lbs.
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