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.
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 analytic and communication skills required as well as knowledge of HIPAA, 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.