Qualifications:
Qualifications: Education Required: • Associate's degree in Healthcare, Nursing, Social Work or a related area or equivalent relevant work experience is required Experience Required: • 2 years of office experience, specifically in either a high volume data entry office, customer service call center, or health care office administration department. Preferred/Desirable: • Experience with FACETS or other healthcare database. • Experience with Health Plan Utilization / Claims departments. • Prior customer service experience. • Bilingual skills, fluency in Spanish. Certification or Conditions of Employment: • Pre-employment background check. Competencies, Skills, and Attributes: • Bi-lingual preferred. • Strong customer service skills and diplomacy skills. • Strong oral, listening, interviewing, interpersonal, written, and verbal communication skills; the ability to interact and work successfully with internal and external colleagues. • Ability to effectively prioritize and manage multiple tasks in a fast-paced environment. • Ability to prioritize work when processing referrals and authorization requests per guidelines and within specific Turn Around Timeframes. • Ability to process high volumes of requests with a 95% or greater accuracy rate. • Competency with standard Microsoft Office applications, particularly MS Outlook and MS Word, and other data entry processing applications. Working Conditions and Physical Effort: • Regular and reliable attendance is an essential function of the position. • Fast paced, call center environment • Ability to work OT if required • Work is normally performed in a typical interior/office work environment. • No or very limited physical effort required. No or very limited exposure to physical risk.
Responsibilities:
Job Summary: Functions as a team member working telephonically in collaboration with the Inpatient Utilization Management Clinician to ensure receipt of clinical information and appropriate discharge planning. Key Functions/Responsibilities: • Screens all inpatient admissions to determine what needs to be referred to Inpatient Utilization Management Clinician • Requests clinical information from facilities according to workflow (SPAD/POC) and updates authorization in documentation system per workflow, sending letters as appropriate. • Ensures that reminder is sent to Clinician for review on the appropriate day. • Refer for RC2 Upgrade and High Cost referrals as appropriate or as directed Clinician • Refer to CM any member that meets the established guidelines as directed by Clinician • Requests discharge dates from facilities according to workflow • Track and report to Public Partnerships Mass Health members in long term care according to Mass Health guidelines. • Initiate discharge planning for specific diagnoses/conditions per workflow. Supervision Exercised: • None Supervision Received: • Direct supervision is received weekly.
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Last updated on Sep 9, 2019