- Research and resolve UM inventory accordingly to meet productivity and quality standards to include:
- Claims reports with reconciliation needs
- Information received through Right Fax
- Information received through email
- Or any other methods of receipt (phone calls, etc.)
- Coordinates initial screening for UM claim reviews through claim queue
- Prepares administrative files for Medical Directors, UM Nurses and Case Managers
- Contacts provider offices to obtain clinical information for medical review by a clinician to meet Center for Medicare and Medicaid Services (CMS), state and health plan guidelines/regulations.
- Documents and follows-up on all assigned inventory, utilizing on-line systems and procedures, according to established guidelines
- Maintains knowledge of various health plan partner benefits, networks, CMS regulations and health plan partner policies
- Utilize experience and judgement to plan, accomplish goals and effectively resolve each assigned task
- Receives and responds to telephone calls through the UM Phone Queue, as needed
- Performs all other related duties as assigned
- High School Diploma / GED
- 1+ years managed care experience in Prior Authorization or Claim Review
- 6+ months experience using Medical Terminology, ICD-9/ICD-10 and CPT
- 6+ months experience working in an environment that is based on meeting metrics and daily goals (example - handling 40 cases per day )
- Proficiency with Microsoft Office applications (examples: Microsoft Outlook, Microsoft Access, Microsoft Word, Microsoft Excel)
- Ability to work onsite at 19500 W Interstate, San Antonio, TX
- Must be 18 years of age OR older
- Ability to work full-time, Monday - Friday between 7:00am - 4:00pm
- 2+ years managed care experience in Prior Authorization or Claim Review
- Proficient with Medicare processing guidelines, working knowledge of medical contracts
- Exceptional ability to organize, prioritize and communicate effectively.
- Ability to navigate multiple systems
- Ability to work in a fast-paced environment
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Clinical Administrative Coordinator - San Antonio, United States - UnitedHealth Group Inc.
Description
WellMed was founded in 1990 with a vision of being a physician-led company that could change the face of healthcare delivery for seniors.
Through the WellMed Care Model, we specialize in helping our patients stay healthy by providing the care they need from doctors who care about them.
We partner with multiple Medicare Advantage health plans in Texas and Florida and look forward to continuing growth.This position is responsible for processing Utilization Management (UM) Inventory. MCR Coordinator is responsible for handling customer service or provider calls as needed. Coordinates UM processes with WellMed Medical Directors, UM Nurses, hospitals, physicians and other various departments. MCR Coordinator is responsible for providing clerical support to WellMed clinical staff for their medical necessity review process. MCR Coordinator is expected to maintain production and quality standards.
This position is full-time, Monday - Friday.
Employees are required to have flexibility to work 8-hour shift schedules during our normal business hours of 7:00am - 4:00pm.
It may be necessary, given the business need, to work occasional overtime. Our office is located at 19500 W Interstate San Antonio, TX.We offer - 4 months of paid training. The hours of training will be 7:00am - 4:00pm, Monday - Friday. Training will be conducted onsite.
Primary Responsibilities:
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
Preferred Qualifications:
Soft Skills:
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone.
Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes.
We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
Diversity creates a healthier atmosphere:
UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.#RPO #RED
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