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Intake Care Senior Representative (AL)
Ref No.: 19-04076
Location: Birmingham, Alabama
Position Title: Care Senior Associate - Intake Care Senior Representative
Reports to: Director of Health Services
Location: Birmingham, AL (Hoover area)
Hourly Rate: $18+ dependent upon experience
Timeline: August 1 - November with extension determined by performance and attendance
Hours: 8am-5pm, Monday through Friday

The Pre-Certification Specialist is responsible for supporting the Precertification Nurse, Medical Director and Director of Health Services by collecting, interpreting and evaluating medical information received for authorization. The Pre-cert Specialist will communicate with internal and external providers regarding authorization status.

Essential Duties and Responsibilities:
  • Receive request for authorization from hospitals, providers, members and vendors; Meet service level goals (e.g., Grade of Service, Average Handle Time, Average Speed to Answer, abandonment rate).
  • Determine authorization requirements based on company policy, member benefit grid and provider status.
  • Review authorization requests and make determinations on correct authorization process (i.e. auto approve, refer to Precert Nurse or Medical Director).
  • Maintain benchmark standards for TAT (Turn Around Time) as established by the organization.
  • Provide determinations on authorizations request to members and/or providers based on benchmark standards for authorization decisions. Process extensions of authorizations as appropriate.
  • Processes denials including correspondence sent to families, members, facilities and applicable contracted providers
  • Notifies responsible parties prior to initiation of denial letter and ensures that member and responsible party understand details of the letter and the appeals processes to follow
  • Completes review of non authorized medical claims
  • Proficient knowledge of departmental policies and procedures; knowledge of Medicare, HIPPA and NCQA ;
  • Professional demeanor and the ability to work effectively within a team or independently;
  • Flexible with the ability to shift priorities when required;
  • Maintains regular and acceptable attendance at such level as is determined at the employer's sole discretion
  • Other duties as requested

Qualifications:
  • High School Diploma and 3-4 years experience in a managed care environment.
  • Must be proficient in medical terminology, CPT and ICD-9 coding