Job Details
SUMMARY: The Health Services Coordinator acts as the primary resource and contact for providers relating to service requests and correspond with members and providers as to decision(s) made regarding requests for these services. Also assist Case Managers with research and correspondence related to service requests. Adhere to all HNE, HIPAA, DOI and NCQA standards, policies and procedures relating to member confidentiality, documentation, quality, and turnaround times.
ESSENTIAL FUNCTIONS:
Productivity - 40%
- Maintains productivity standards for authorization entry, letter generating and auditing
- Performs review for out-of-network referrals for applicable plans using set guidelines
- Coordinates and authorizes services based on entitled benefits, defined criteria and set guidelines
- Pre-screens criteria-based procedures before directing to clinical reviewer
- Maintains fully-funded and self-funded queue coverage responding to inbound inquiries from members and providers by providing product and benefit information
- Assists in the member appeals process by entering authorizations as appropriate
- Understands the concepts, features, benefits, disclosures and provisions of government health insurance programs.
- Enters data from Medicare Advantage Health Risk Assessments and forwards to Case Manager for review
- Adheres to CMS guidelines and regulations
- Assists in response to Prudent Lay Person letters
- Assists in claims review by helping to research and resolve complex issues
- Provides product, eligibility and benefit information specific to each special account
- Ongoing benefit audits for accuracy and error
Internal Customer Support and Education - 40%
- First point of contact for all Health Services related benefits and issues
- Works collaboratively and cohesively with all members of the CSI Team in order to coordinate a continuum of c care for members consistent with the members' health care goals and needs
- Provides support to Case Managers for trouble-shooting and education
- Performs duties and assists supervisor, manager, and Case Manager in administrative functions
- Maintains Spark coverage responding to inquiries from respective HNE departments
- Provides support and education to Member Services, Provider Relations and Sales Departments including but limited to researching and resolving complex issues, authorization entry for member transactions, response to member inquiries, provide education of health services processes and standards
- Processes ASO benefit exceptions as needed
External Member Support and Education - 20%
- Provides education on criteria-based procedures to members and physicians
- Works as a member advocate promoting a personal and accountable relationship
- Makes outbound calls to members to educate them on benefit information
- Outreaches to members having called in on the Disease Management Telephone Queue, mailing requested materials, and/or signing up for programs.
MINIMUM REQUIREMENTS: High School diploma or equivalent and a minimum of 2 years' experience in a medical administrative role in a physician's office, clinic or other medical facility or the insurance industry.
- Certified Medical Assistant preferred
- Experience with and/or specific training in medical terminology
- Beginner to intermediate skill level with Microsoft Word and Excel
- Typing speed and accuracy
- Very good problem solving, organizational and prioritizing skills
- Excellent listening skills
- Very good ability to effectively interact with a multi-cultural membership
- Ability to work independently and as a team member
- Ability to communicate effectively with others, on the telephone and in person
- May require demonstrated proficiency in self-funded line of business
WORKING CONDITIONS: Works in a standard office-based environment