- Manage department phone queue and process calls according to the Enterprise wide Call Validation Policy, which includes preauthorization requests, referrals, hospital admissions, medical information and determination status.
- Handle multiple requests and complete within expected deadlines.
- Ability to efficiently and professionally communicate with members and providers.
- Initiate preauthorization and referral process verify documentation from external stakeholders, and enter information into the computer system.
- Assist clinical staff with obtaining information for preauthorization and retroactive claim reviews. Request medical records as required and document status of request.
- Make guideline-directed determinations under the authority and direction of the professional staff.
- Assist with and participate in meetings and trainings as assigned.
- Scan, copy, send out notices, and perform a variety of clerical tasks and special projects for the department, as needed.
- Represent department, both internally and externally, as required.
- Meet department and company performance and attendance expectations.
- Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
- Perform other duties as assigned.
- Building Customer Loyalty
- Building Strategic Work Relationships
- Contributing to Team Success
- Planning and Organizing
- Continuous Improvement
- Adaptability
- Building Trust
- Work Standards
- We are committed to doing the right thing.
- We are one team working toward a common goal.
- We are each responsible for customer service.
- We practice open communication at all levels of the company to foster individual, team and company growth.
- We actively participate in efforts to improve our many communities-internally and externally.
- We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
- We encourage creativity, innovation, and the pursuit of excellence.
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Health Services Representative II - Springfield, United States - PacificSource
Description
Looking for a way to make an impact and help people?
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.
Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.
Position Overview:
Provide administrative and analytic support for the Health Services Department. Handle initial steps of preauthorization's, referrals and/or claims reviews. Gather data from hospitals, providers, and members. Research eligibility, benefits, and planned medical interventions. Obtain clinical information and other data needed to make determinations. Enter appropriate information into system. Assist professional staff with utilization management processes.
Essential Functions:
Supporting Responsibilities:
Work Experience: 1+ year of experience in the health insurance industry and/or a strong medical background required. Some call center experience preferred. Other relevant work experience may be considered.
Education, Certificates, Licenses, Registration: High school diploma or equivalent required.
Knowledge: Microsoft Office software including Word and Excel. CPT/ICD10 coding, call tracking software. Thorough knowledge of utilization management, including referral, inpatient notification and preauthorization, to support continuity of care. Knowledge of health plan eligibility, benefits, medical interventions and management. General clerical, excellent written and oral communications skills, medical terminology required. Ability to analyze and provide timely and accurate responses. Excellent public relations and customer service skills.
Competencies
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately less than 5% of the time.
Skills:
Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, TeamworkOur Values
We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:
Physical Requirements:Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer:This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
