GENERAL SUMMARY
Responsible for reviewing and analyzing information to make medical determinations based on established criteria, policies, and guidelines. Applies clinical knowledge to assess the level of services for retrospective claims review.
ESSENTIAL RESPONSIBILITIES
- Under general direction, conducts medical reviews ofrequests for equipment and services for medical appropriateness for Workers' Compensation plans in support of company medical payment criteria, policies, and guidelines and according to state law withinthe state where claim originated.
- Processes and/or reviews equipment and service requests for compliance and level of care in a timely manner that meets or exceeds production and quality goals. Reviews physician, facility, and specialty claims and adjustments to ensure compliance with established company policies and procedures.
- Consults with management as required for assistance with questions and complex issues that may arise.
- Assesses and investigates information to respond to and resolve inquiries including, but not limited to authorizations, payments, denials, and coordination of benefits.
- Interfaces with clients by telephone, in writing, and/or in person to answer questions and resolve process issues.
- May identify training needs within the team. May train service teams based on outcomes of medical reviews as well as process and/or procedure changes.
- Identifies and recommends opportunities for cost savings and improving outcomes.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) with active state license in the state where work is performed required.
- Previous (3-5 years) clinical experience required.
- Knowledge of medical terminology and ICD-9, CPT-4, and HCPCS coding.
- Experience in workers compensation, orthopedics, managed care, utilization review, claims review, and/or health care products preferred.
- May require knowledge and expertise in multi-state laws.
- Strong analytical and problem solving skills.
- Excellent organizational, interpersonal, and communication skills.
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: Tucson, AZ, US
Organization: 43007 - First Script Network Services
Schedule: Full-time
Job Posting: 2012-12-12 00:00:00.0
Job ID: 1212592