Associate Care Management Coordinator

Highmark Health; Illinois; On-site; USD 35,000 - 60,000; Full time

Job summary

An established industry player is seeking a detail-oriented Care Management Coordinator to join their dynamic team. In this role, you'll be responsible for processing pre-certification requests for health care services, ensuring compliance with regulatory guidelines while maintaining high standards of customer service. You'll communicate effectively with various stakeholders, manage service requests, and contribute to a supportive work environment. This position offers a unique opportunity to make a meaningful impact within the healthcare sector while developing your skills in a collaborative and fast-paced setting.

Qualifications

• Experience in customer service and medical terminology is preferred.
• Typing and computer skills are essential for this role.

Responsibilities

• Process pre-certification requests for health care services efficiently.
• Communicate effectively with internal and external stakeholders.
• Maintain department standards for call volume and response time.

Skills

Customer Service

Typing Skills

Medical Terminology

ICD-9 and CPT Coding

Education

High School Diploma / GED

Associates Degree or Certification in Health Related Occupation

Job description

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 the organization's policies, procedures and regulatory requirements. Document, process and route requests for services to the nurse reviewer and other departments based on documentation procedures, including review type, clinical information, and decision timeframes. Follow policies and procedures to assure case completion and compliance with state and federal regulatory agencies. Maintain or exceed department standards for call volume, response time and related production and quality measures. May interact with other departments and providers to resolve cases.

ESSENTIAL RESPONSIBILITIES :

• Communicate effectivelyProactively inform designated individuals of the status of work assignment to assure decision timeframes and notification requirements are metCommunicate effectively with Utilization Management Staff, providers, other internal and external customers and management
• Route Cases Based on Established GuidelinesProvide accurate and timely routing of service requests to the nurse reviewer to assure that the decision and notification timeframes are in compliance with regulatory guidelinesProcess service requests meeting established guidelines, and document and route requests that are not permittedRequest 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 standardsAdhere to line of business phone standards to assure regulatory requirements are metUtilize phone functions to monitor the number of calls in queue and wait timeUtilize daily phone standard reports to assess opportunities for self improvementMeet or exceed standards for other production and quality measures
• Other duties as assigned or requested.

QUALIFICATIONS

Preferred

• 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

Language (Other than English) :

None

Travel Requirement : 0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products / services (sales employees)

Never

Physical work site required

Lifting : up to 10 pounds

Constantly

Lifting : 10 to 25 pounds

Occasionally

Lifting : 25 to 50 pounds

Rarely

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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Care Management Coordinator • IL, Working at Home, Illinois