Care Review Processor

SmartRecruiters, Inc.; El Paso (TX); On-site; USD 36,000 - 54,000; Full time

Job summary

SmartRecruiters, Inc. is seeking an Utilization Review support professional in the United States. This role involves processing authorization requests, verifying eligibility and benefits, and assigning appropriate billing codes.

The candidate will collaborate with multiple departments to ensure continuity of care and maintain HIPAA compliance. Required experience includes 1–4 years in a Utilization Review setting, hospital or healthcare clerical/billing background, and familiarity with medical

Qualifications

• 1-4 years of experience in a Utilization Review Department in a Managed Care Environment.
• Experience with Medical Terminology.
• Previous Hospital or Healthcare clerical, audit or billing experience.

Responsibilities

• Provide computer entries of authorization requests and provider inquiries by phone, mail, or fax.
• Verify member eligibility and benefits; determine provider status and appropriateness.
• Assign billing codes (ICD-9/ICD-10 and/or CPT/HCPC).
• Respond to authorization requests for services per client timeframes.
• Collaborate with Behavioral Health and Long Term Care where needed.
• Request missing information from physicians per guidelines; liaison with Medical Director.
• Deliver excellent customer service for internal and external customers.
• Meet department quality standards and productivity targets.
• Maintain HIPAA confidentiality.

Skills

Customer Service

Computer Skills

Medical Terminology

Education

High School Diploma/GED

Job description

Top Three Skill Sets: Customer Service, Computer Skills and medical terminology

Job Description :

• Provide computer entries of authorization request/provider inquiries by phone, mail, or fax. Including: Verify member eligibility and benefits, Determine provider contracting status and appropriateness, Determine diagnosis and treatment request Assign billing codes (ICD-9/ICD-10 and/or CPT/HCPC codes), Determine COB status, Verify inpatient hospital census-admits and discharges, Perform action required per protocol using the appropriate Database.
• Respond to requests for authorization of services submitted to CAM via phone, fax and mail according to Client’s operational timeframes.
• Participates in interdepartmental integration and collaboration to enhance the continuity of care for Client members including Behavioral Health and Long Term Care.
• Contact physician offices according to Department guidelines to request missing information from authorization requests or for additional information as requested by the Medical Director.
• Provide excellent customer service for internal and external customers.
• Meet department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores.
• Notify Care Access and Monitoring Nurses and case managers of hospital admissions and changes in member status.
• Meet productivity standards.
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).

EDUCATION:

• Required Education: High School Diploma/GED
• Required Experience: 1-4 years of experience in a Utilization Review Department in a Managed Care Environment.
• Previous Hospital or Healthcare clerical, audit or billing experience. Experience with Medical Terminology

Additional Information

All your information will be kept confidential according to EEO guidelines.