Highmark Health Associate Care Management Coordinator in Pittsburgh, Pennsylvania

Description

JOB SUMMARY

This job perform accurate and timely processing of pre-certification requests for authorization of medically necessary health care services at the appropriate level of care, based on the benefits for the line of business, and in compliance with Gateway policies, procedures and regulatory requirements. The incumbent documents, processes and routes requests for services to the nurse reviewer and other departments based on documentation procedures, including review type, clinical information, and decision timeframes. Follows policies and procedures to assure case completion and compliance with state and federal regulatory agencies.Maintains or exceeds department standards for call volume, response time and related production and quality measures. Interacts with other departments and providers to resolve cases.

ESSENTIAL RESPONSIBILITIES

  • Proactively inform designated individuals of the status of work assignment to assure decision timeframes and notification requirements are met.

  • Communicate effectively with Utilization Management Staff, providers, other internal and external customers and management.

  • Route cases based on established guidelines.

  • Provide accurate and timely routing of service requests to the nurse reviewer to assure that the decision and notification timeframes are in compliance with regulatory guidelines.

  • Process service requests meeting established guidelines, and document and route requests that are not permitted.

  • Request additional information verbally and in writing when the information provided is not adequate to make a medical necessity determination.

  • Maintain or exceed department call center standards.

  • Adhere to line of business phone standards to assure regulatory requirements are met.

  • Utilize phone functions to monitor the number of calls in queue and wait time.

  • Utilize daily phone standard reports to assess opportunities for self improvement.

  • Meet or exceed standards for other production and quality measures.

  • Other duties as assigned or requested.

QUALIFICATIONS

Minimum

  • High School Diploma / GED

  • Experience in customer service

  • Experience in typing, keyboard and computer skills

  • Work experience in medical terminology

  • Associates degree or certification in a health related occupation

  • Work experience with ICD-9 and/or CPT coding

Preferred

  • None

Skills

  • None

SCOPE OF RESPONSIBILITY

Does this role supervise/manage other employees?

No

WORK ENVIRONMENT

Is Travel Required?

No

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies

REQNUMBER: J132001

Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity