This position receives/responds to provider authorization issues and/or RCM inquiries on claim issues. Researches information by reviewing plan, eligibility, patient notes, and authorizations to determine appropriate resolution. Works with CSC or RCM to identify areas of opportunity and recommend solutions. Completes special assignments and analyzes provider requests. Assists other departments and interacts directly with providers.
• Handles various provider authorization projects which include researching, resolving, and documenting provider authorization issues.
• Handles RCM authorization and intake changes required for claims and billing processing within a 48 hour turn-around time frame.
• Analyzes data and determines if CareCentrix guidelines have been followed by CSC when providing authorizations to providers by researching plan, eligibility, and patient authorization information.
• Tracks CSC errors and communicates to up-line management for coaching and training purposes.
• Creates or modifies authorizations when necessary based on individual provider and carrier contracts.
• Performs analysis on possible recoupments and processes recoupments.
• Participates in and contributes to performance improvement activities.
• Participates in special projects and performances other duties as assigned.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
• Candidate will possess excellent communication (verbal/written), organizational and interpersonal skills.
• Manage multiple tasks, be detail oriented, be responsive, and demonstrate independent thought and critical thinking.
• This position requires excellent communication, customer service and problem solving skills, as well as the ability to effectively interact with all levels of management and a highly diverse clientele.
• Must have strong organizational skills and be able to effectively manage and prioritize tasks.
• Must be able to problem solve difficult situations with internal and external customers, and with process and/or system issues.
• Must have strong organizational skills and be able to manage and prioritize tasks in a timely manner.
• Must have the ability to visualize, listen and resolve customer inquiries, while demonstrating a positive persona of the Company.
• Abides by and demonstrates the company Mission – Vision – Values through both behavior and job performance on a day-to-day basis.
• Convey a strong professional image, exhibit interest and positive attitude toward all assigned work.
• Adheres to and participates in Company’s mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.
High School Diploma plus a minimum of 4 years of experience in medical claims, customer service, claims processing, medical terminology, medical services or equivalent experience required. Knowledge of basic spreadsheet/word processing/data entry and basic math skills required. Has expert knowledge of department systems and processes as well as CareCentrix business protocols and relevant legal and regulatory knowledge. Knowledge of Utilization Management and URAC standards preferred. Effective analytical and communication skills required as well as knowledge of HIPPA, The Fair Credit and Collections Act, HCPC, CPT, ICD-9 coding, intermediate competency of Microsoft Office Applications, and mathematical calculations.
CareCentrix maintains a drug-free workplace in accordance with Florida’s Drug Free Workplace Law.