Medical Management Coordinator - Jefferson Health Plan

Jefferson Health; Philadelphia (Philadelphia County); In loco; USD 45.000 - 65.000; Tempo pieno

Vantaggi offerti da questo lavoro

Medical insurance

Tuition assistance

Retirement plans

Vision insurance

Dental insurance

Descrizione del lavoro

Jefferson Health in Philadelphia seeks an Authorization Coordinator to collect and process inpatient and outpatient authorization requests via Medical Management system, provider portal, and call center functions. The coordinator facilitates authorizations through the technical authorization and payment cycles.

Responsibilities include processing admissions authorizations, communicating with providers, ensuring data accuracy, monitoring authorizations, and supporting clinical case managers.

Competenze

• High School Diploma or GED is required.
• 2 years in health care experience.
• Proficient use of Microsoft Office suite (Word, PowerPoint, Excel) is required.
• Knowledge of medical terminology, utilization review systems, hospital admission systems, and health care claims or medical office administration.
• Ability to work independently and as a team player, and communicate effectively with coworkers, members and providers.
• Excellent organizational skills and ability to handle multiple responsibilities.
• Ability to work on detailed reports and maintain accuracy.
• Excellent telephone and verbal/written communication skills.

Mansioni

• Follow all company and department policy and procedures.
• Process and create authorization requests for emergency admissions, elective inpatient admissions, outpatient services, and maternity/newborn deliveries per guidelines.
• Identify duplication of services and communicate to appropriate team members.
• Follow up to confirm outstanding prior authorizations and update the system.
• Manage authorizations through the provider portal via the 278 transaction and perform QA of required fields.
• Process all cases assigned by leadership.
• Monitor and prepare clinical information and records for submission to the Quality Improvement Organization (QIO).
• Create cases for non-par providers with a temporary provider ID and refer for MHS setup for claims payment.
• Monitor provider portal for failed/duplicate authorizations for re-education.
• Provide continuous call center service in a prompt and courteous manner.
• Verify member eligibility via internal eligibility system or DHS terminal and alert case managers of changes.
• Code all services using ICD-10, CPT, and HCPCS coding systems.
• Reconcile claim discrepancies and meet SLA of 3 business days.
• Assist with member/provider questions regarding service authorization and general customer service.
• Support Clinical Case Managers by closing cases when applicable.
• Maintain key indicator thresholds for department phone service.
• Triage Medical Management clinical faxes for timely medical necessity review.
• Attach faxes to member cases in Medical Management System.
• Work with Applications Systems Management (ASM) to identify system failures affecting payments and data integrity.

Conoscenze

Communication

Team player

Independent work

Detail oriented

Organizational skills

Verbal/written communication

Formazione

High School Diploma/GED

Strumenti

Microsoft Office Suite

Medical Management System

Provider portal

Utilization review systems

Descrizione del lavoro

Job Details

Works under general supervision, collect and process information related to inpatient and outpatient authorization requests for services via Medical Management system, provider portal and call center function. The coordinator also facilitates authorizations through the technical authorization and payment cycles.

Number of Positions In Requisition

1

Job Details

Works under general supervision, collect and process information related to inpatient and outpatient authorization requests for services via Medical Management system, provider portal and call center function. The coordinator also facilitates authorizations through the technical authorization and payment cycles.

Summary

Job Description

Works under general supervision, collect and process information related to inpatient and outpatient authorization requests for services via Medical Management system, provider portal and call center function. The coordinator also facilitates authorizations through the technical authorization and payment cycles.

Job Duties

• Follow all company and department policy and procedures.
• Process and create authorizations requests for emergency admissions, elective inpatient admissions, outpatient services in a medical and home setting, DME emergent and urgent maternity and newborn delivery admissions as per departmental guidelines.
• Identify duplication of services and communicate to appropriates team members.
• Follow up to confirm outstanding prior authorizations to confirm status and update system and authorization.
• Manage authorizations coming through the provider portal via the 278 transaction into Medical management system and perform quality assurance of all required fields prior to reassignment to appropriate case manager.
• Responsible to process all cases assigned by leadership.
• Monitors and prepares clinical information and record maintenance for submission to QIO (Quality Improvement Organization).
• Create cases for non -par providers with a temporary provider ID and collect pertinent provider information and refer via Medical Management System to Network Management team for completion of MHS set up for claims payment.
• Monitor provider portal for failed and duplicate authorizations for provider re-education.
• Provide continuous call center telephone service in a prompt and courteous manner. Maintaining call service thresholds.
• Verify member’s eligibility via internal eligibility system and/ or DHS terminal and alert case managers of change in eligibility status.
• Code all services accurately using appropriate ICD-10 codes CPT and HCPCS coding systems.
• Reconcile claim discrepancies via Service forms sent and meet the Service Level Agreement of (3) three business days turnaround time.
• Identify resolution of outstanding claims issues generated by a provider inquiry and or written request.
• Assist member services and provider services in addressing member or provider questions regarding service authorization questions and, general customer service for both internal and external customers.
• Support Clinical Case Managers by closing cases when applicable.
• Maintain Key Indicator thresholds for established phone service for the department
• Triage of Medical Management clinical faxes for timely medical necessity review.
• Attach faxes to the member’s case in (Medical Management System).
• Work with Applications Systems Management (ASM) team to identify system failures that directly impact claim payment and data integrity
  

Minimum Qualifications

• High School Diploma/GED
• 2 years in health care experience
• Proficient use of Microsoft Office suite (Word, PowerPoint, Excel) required.
• Knowledge of medical terminology, utilization review systems, hospital admission systems, health care claims or medical office administration.
• Demonstrate ability to work and communicate effectively with co-workers, members and providers at the owner institutions.
• Ability to work independently and as a team player.
• Ability to work on detailed reports.
• Demonstrate excellent organizational skills and ability to competently handle multiple responsibilities at one time
• Demonstrate excellent telephone and verbal/written communication skills.

Physical Demands

Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.
Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Health Partners Plans, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America
Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.
Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.