GENERAL SUMMARY
Under the direct supervision of clinical staff, performs assigned duties, including telephonic support for on-line authorization of routine services, contacting specialty care providers, monitoring patient eligibility, and performing on-line data entry of routine authorizations/denials.
ESSENTIAL RESPONSIBILITIES
- Performs telephonic support for on-line authorization of routine services.
- Provides direct support to primary care practices and specialty care providers regarding utilization, authorization, and referral activities.
- Proficient in the use of ICD-9 and CPT codes.
- Data enters referrals for non-complex services including DME, physical therapy, inpatient and outpatient care, behavioral health services and testing as applicable, and special circumstance requests as defined by Utilization Management.
- Assists in gathering information needed for coordinators/case managers to determine continued authorization.
- Provides data entry for care which has been arranged by the Pre-Authorization Coordinators.
- Contacts providers with authorization, denial and appeals process information.
- Assists in educating and acts as a resource to primary care practices and specialty care providers.
- Verifies eligibility of members and participating status of providers in IDX.
- Determines member benefit coverage utilizing IDX or group coverage documents.
- May receive pended claims reports on claims received without prior authorization to research and review eligibility and benefit coverage. Upon decision of claim payment status, generates the appropriate referral with notification and exchange of information to the service organization for proper adjudication of claim payment.
- Assists with the identification and reporting of potential quality management issues. Responsible for ensuring these issues are reported to the Quality Management Department.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- High school degree or equivalent. Bachelor’s degree preferred.
- Licensed Mental Health Technician (LMHT), if applicable based on service supported.
- Previous experience (usually 2+ years) in general office environment preferred.
- Familiarity with medical terminology required.
- Proficiency with computer systems, ICD-9/CPT coding, and multi-line phone systems preferred.
- Excellent communication skills required.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Administrative Support Workers
Primary Location: Newark, DE, US
Organization: 15000 - CHC of Delaware
Schedule: Full-time
Job Posting: 2013-01-30 00:00:00.0
Job ID: 1310374