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  Maintain data accuracy and adhere to Summary Plan Description (SPD) time frames for creating and modifying authorization on Medical claims system (QNXT) for outpatient, homecare services and codes requiring authorization
• Review and respond to oral and written inquiries from members and providers regarding homecare, outpatient, other benefit services, Appeals, Inquiries and Retrospective Reviews
• Review, gather relevant documentation and prepare cases in DMS for submission to manager/vendors for Appeals, Inquiries and Retrospective Reviews
• Maintain accurate documentation in QNXT, Aerial Case Management Software, Document Management System (DMS) and Provider Link
• Conduct telephonic and email outreach to members, physicians, and providers to educate on Benefits and Service Coordination, request clinical records, obtain member appeal auth form and case specific information, provide appropriate referrals and timely follow ups, assist with discharge planning as needed to ensure optimal outcomes
• Track and monitor 1st, 2nd and 3rd level appeals, inquiries and retro reviews on designated logs
• Assist members to navigate through the healthcare delivery system and appeal process
• Prepare cases for unresolved complex issues for presentation to management
• Submit Monthly productivity and status reports as needed
• Facilitate, Interact and provide ongoing follow up with other departments, vendors and providers to troubleshoot and resolve issues
• Prepare correspondence for member, provider/vendor and follow up to obtain required data and generate memos and reports as required
• Perform special projects and assignments as directed by management

Qualifications

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  High School Diploma or GED required; College degree preferred in Healthcare, Business or related field
• Minimum two (2) years-experience with Health Plan, Managed Care Organizations and Providers in case management and utilization management programs preferred
• Strong knowledge of utilization review, case management, medical terminology, CPT, HCPCS and ICD10 codes
• Basic skill level in Microsoft Word and Excel required
• Knowledge of clinical documentation systems (ICIS) and vendor portals (eviCore portal)
• Experience work with external vendors
• Solid understanding of eligibility & benefits with commercial carriers, Medicare & Medicaid
• Strong clinical knowledge and excellent critical thinking, organizational and problem-solving skills
• Effective verbal and written communication skills; excellent time management and project management skills