Healthcare Representative

EPITEC; Berlin (VT); On-site; USD 40,000 - 60,000; Full time

Benefits offered by this job

401(k)

Job summary

A leading company seeks a Healthcare Representative to coordinate medical review cycles and ensure proper claims processing. The role requires 1-3 years of experience in healthcare, with skills in customer service and data systems. Successful applicants will possess a high school diploma, with preferred associate degrees. The position is fully remote, emphasizing strong communication skills and a deep understanding of healthcare benefits.

Qualifications

• 1-3 years' experience in the healthcare industry, preferably health insurance.
• Understanding of claims adjudication and medical coding (e.g., ICD-9, CPT4).
• Strong written and oral communications skills.

Responsibilities

• Facilitate preadmission/admission reviews and maintain electronic medical records.
• Evaluate incoming requests for member/benefit eligibility.
• Provide exceptional customer service and manage department communications.

Skills

Subject Matter Expertise

Computer Skills

Communication Skills

Education

High School Diploma

Associate's degree preferred

Tools

MS Office Applications

AS400

Customer Focus

OnBase

Job description

Direct message the job poster from EPITEC

• Will this position be required to work onsite for any reason at any time? No.
• Candidate must be comfortable with supporting a 3-month ongoing contract.
• Candidate must supply their own laptop or home computer.

The Representative will:

• Facilitate and coordinate preadmission/admission reviews, prior approvals and referral requests through the medical review cycle in compliance with Rule 10, DOL (department of labor), NCQA (National Committee for Quality Assurance), and URAC (Utilization Review Accreditation Commission) timeliness requirements.
• Generate and perform quality assurance of correspondence, entering authorizations to ensure appropriate claims processing, and maintaining electronic medical records.
• Answer department phone calls and evaluating issues and questions from internal and external customers.
• Provide exceptional customer service when interacting with all internal and external customers and always maintains the highest level of confidentiality.

Representative Responsibilities:

• Evaluate incoming requests and determine proper distribution throughout the department and company.
• Analyze and research requests to determine member/benefit eligibility, including identifying OPL, waiting periods, benefit maximums, etc.
• Coordinate requests and create cases for prior approval and pre-certification in multiple systems (including Customer Focus, Acuity, MHS, AS400) for review by clinical reviewers.
• Identify and refer members for case management based on diagnoses and types of service being requested.
• Enter and update authorizations to ensure appropriate claims processing based on clinical reviewers’ decision.
• Correspond with members and providers regarding decisions about requested services and to obtain medical records when necessary.
• Participate in on-going efforts to comply with NCQA, Rule 10 and URAC standards by performing quality assurance of outgoing correspondence, understanding time variations of requirements and responding to requests within the timeliness guidelines.
• Work collaboratively with other departments to obtain additional information to resolve claims, inquiry, and prior approval/pre-certification requests.
• Professionally and courteously answer, manage and appropriately route department telephone calls, processing calls regarding pre-certification and prior approval of services and referring to other departments when necessary.
• Review and respond to issues and questions from internal and external customers, both verbally and in writing.
• Act as a liaison between the members, outside vendors and providers.
• Acquire and implement a high level of professional and service excellence when interacting with all customers, external as well as internal.
• Develop cooperative relationships both within and outside of the company.
• Provide clear, concise, and accurate interpretation of Plan certificate language, benefit administration, and all information communicated to customers.
• Manage electronic medical records and all incoming PHI, always maintaining the highest level of confidentiality.
• Assist clinical staff in gathering data, researching claims/authorizations, obtaining medical records, and other duties as needed.

Top Required Skills/Experience:

• Subject Matter Expertise (Understanding of plan benefits and products, claims adjudication and data systems, medical terminology and medical coding, to include ICD-9, HCPCS, and CPT4, URAC, NCQA, Rule 10, DOL, and other regulatory standards pertaining to Case/Care Management)
• Computer Skills - Competent in use of MS Office Applications, AS400 legacy, MHS, Lotus Notes, Customer Focus, OnBase, The Knowledge Center, web browsing, Acuity and phone system.
• Strong written and oral communications skills with advanced listening skills to be able to identify provider and subscriber concerns

Required Skills/Experience include:

• 1-3 years' experience in the healthcare industry, preferably health insurance

Preferred Skills/Experience include:

• Experience in health insurance claims processing

Education/Certifications include:

• High School Diploma
• Associate's degree preferred

Seniority level

• Seniority level

  Not Applicable

Employment type

• Employment type

  Contract

Job function

• Job function

  Customer Service

• Industries

  Health and Human Services

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Inferred from the description for this job

401(k)

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