SUMMARY

Under general supervision, following established procedures, assist and direct patients in an empathetic and caring manner, efficiently and timely, and complete appropriate documentation. Respond to provider inquiries and attempt to resolve provider concerns or refer to management for resolution.

ESSENTIAL DUTIES AND RESPONSIBILITIES, include the following:

• Comply UM and Customer Service policy and procedure.
• Read all new P&P’s and review others annually
• Answer incoming calls from our customers to include but not limited to: members, providers, health plans, insurance brokers, and hospitals in accordance to HIPAA guidelines.
• Answer and assist at least an average minimum of 60 calls per day.
• Maintain an average handle time of no more than 7minutes
• Maintain an average quality score of no less than 3 points (point scale 0-4)
• Maintain an average wait time of 7 minutes or less
• Research and resolve authorizations, claims, eligibility inquiries and any additional concerns in a timely fashion.
• Accurate documentation of calls into customer service module using appropriate wrap up codes.
• Educate contracted providers about TAT’s, Portal access and other information as needed, document provider education in customer service module; utilized fax reminder memo as needed
• Address Portal inquiries from the providers and respond within 1 business day
• Release and or modify authorization as per established UM protocol.
• Maintain strictest confidentiality at all times.
• Provider outreach communications via mail or telephone regarding utilization matters..
• Assist other departments when back up is required.
• Provide quality service to customers.
• Retrieve and return voicemail calls from customers and respond before the end of the day.
• Communicate effectively with customers in a professional and respectful manner.
• Must meet at least with a score of 3 (Meets all standards) the Quality Assurance audit standards at all times
• Report to Supervisor/Manager on activities and/or problems occurring throughout the day
• Performs other duties, projects and actions as assigned

QUALIFICATIONS:

• High School Graduate or equivalent
• A minimum of one year experience in managed care environment to include but not limited to an IPA or MSO.
• Current knowledge of Managed Care UM procedures
• Knowledge of medical terminology, RVS, CPT, HPCS, ICD-9 codes.
• Proficient with Microsoft applications’ and EZCAP
• Good organizational skills.
• Good verbal and written communication skills.
• Must have the ability to multitask and problem solve in a fast pace work environment
• Personal & Professional Qualities
• Punctuality, precision with details, creativity, etc. would be helpful for this position
• Ability to follow directions and perform work independently according to department standards
• Able to function effectively under time constraint
• Able to maintain confidentiality at all times
• Willingness to accept responsibility and desire to learn new task
• Ability to comply and follow company policies and procedures
• Must be a strong team player, punctual and have excellent attendance record.