+1 908 704 8843      270 Davidson Avenue, Suite 103, Somerset, NJ 08873
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This position supports the Health Services and Utilization Management functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators. Responsibilities:- Performs review of service requests for completeness of information, ...

Job Description

This position supports the Health Services and Utilization Management functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators. 

Responsibilities:

- Performs review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients.
- Handles initial screening for pre-certification requests from physicians/members via incoming calls or correspondence based on scripts and workflows, and under the oversight of clinical staff.
- Prepare, document and route cases in appropriate system for clinical review.
- Initiates call backs and correspondence to members and providers to coordinate and clarify benefits.
- Upon completion of inquiries initiate call back or correspondence to Physicians/Members to coordinate/clarify case completion.
- Review professional medical/claim policy related issues or claims in pending status.
- Upon collection of clinical and non-clinical information MCC can authorize services based upon scripts or algorithms used for pre-review screening.
*Non Clinical staff members are not responsible for conducting any UM review activities that require interpretation of clinical information.

Qualifications:

- High School Diploma required. Some College preferred.
- Requires Knowledge of Medical terminology
- Prefer 1-2 years customer service or medical support related position.
- Prefer knowledge of contracts, enrollment, billing & claims coding/processing, medical terminology and Managed Care principles