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Intake Care Senior Representative (WAH)
Ref No.: 20-02014
Location: Nashville, Tennessee
Intake Care Senior Representative (WAH)
Schedule: Schedule will be Monday-Friday with potential of OT if business needs dictate. Shifts will be assigned. Schedule could vary- 8:30am-5:00pm or 9:00am-5:30pm or 9:30am - 6:00pm
Location: REMOTE
Contract: 4/27/2020 – 8/31/2020
Pay: $21.59 - $23.00 an hour
 
The Care Associate is responsible for supporting the Precertification Nurse, Medical Director and Director of Health Services by collecting, interpreting and evaluating medical information received for authorization.
 
Duties:

 
  • Communicates with internal and external providers regarding authorization status
  • Receives calls 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) within a Call Center environment
  • Receives request for authorization from hospitals, providers, members and vendors. Maintain benchmark standards for TAT (Turnaround Time) as established by the organization
    Determine authorization requirements based on company policy (PPAL/IPAL), member benefit grid and provider status
  • Completes review of non-authorized medical claims
  • Determines authorization requirements based on company policy (PPAL/IPAL), member benefit grid and provider status
  • Reviews authorization requests and makes determinations on correct authorization process (i.e. auto approve, refer to Precert Nurse or Medical Director)
  • May perform research to respond to inquiries and interprets policy provisions to determine most effective response
  • Collaborates on responses to inquiries, grievances, complaints or appeals ranging from routine to moderate complexity
  • Maintains benchmark standards for TAT (Turnaround Time) as established by the organization
  • Provides determinations on authorizations request to members and/or providers based on benchmark standards for authorization decisions
  • Process extensions, Retro or Expedited authorizations as appropriate
  • Completes review of non-authorized medical claims
 
Requirements:
 
  • Proficient knowledge of departmental policies and procedures; knowledge of Medicare, HIPAA and NCQA
  • Must be proficient in medical terminology, CPT and ICD 10 coding
  • Intermediate knowledge of Microsoft Office including SharePoint, Outlook, PowerPoint, Excel, Word
  • Ability to type 45 wpm.
  • Must have reliable internet connection and previous experience working in a remote setting is strongly preferred.
  • High School Diploma and 1-2 years’ experience in a managed care environment and/or customer service experience required
  • 5 years’ experience in a managed care environment and/or customer service strongly preferred
     
Skills:
 
  • 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
  • Ability to work in a dynamic, fast-paced team environment and to promote team concepts
  • Excellent interpersonal skills and the ability to critically think through processes and procedures