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Medical Determination Specialist

1 month ago

St George, United States Zion HealthShare Full time

Who We Are

Zion HealthShare is a nonprofit medical cost-sharing program that provides an organized structure for members to contribute toward each other's medical costs. We offer individuals and organizations across the country an affordable alternative to insurance; this provides peace of mind. Our goal is to be America's leading HealthShare. We strive to meet our members' needs on a personal level by following our core values: inclusive, transparent, simple. Everything we do for our members is to ensure they feel respected and to let them know we truly care about their needs.

Position Summary:

Are you someone who holds either an MA or LPN that wants to work in a fun, fast paced environment with the flexibility to select from different shifts? Then this maybe the perfect opportunity. You will play a vital role to our community by making important decisions for a broad spectrum of medical specialties and conditions. These determinations are based on an established set of guidelines regarding what is eligible for payment. Your ability to work efficiently and in a team setting will be vital to the overall success of Zion HealthShare.

Essential Duties and Responsibilities:

  • Evaluate all Medical Need Submissions received from members to determine eligibility (aka adjudicator) for sharing into medical expenses.
  • Communicate effectively and consult with members, providers, and team members as necessary throughout the determination process.
  • Keep members and providers informed and updated about medical needs through regular verbal and written communication.
  • Act with a sense of urgency in making determinations on medical needs.
  • Maintain HIPAA compliance and company compliance policies.
  • Takes inbound and outbound phone calls from members and providers regarding questions or concerns with the eligibility determination.
  • Providers support to email inbox management.
  • Assists with requests and following up on obtaining medical records.
  • Continuously strive to exceed member expectations ensuring a high level of member satisfaction.
  • Provide recommendations to the Member Guidelines Committee as needed.

Required Skills and Abilities:

  • Professional level of written and verbal communication that demonstrates directness, compassion, and empathy
  • Microsoft Office Suite Proficiency
  • Ability to read and interpret medical records
  • Ability to work effectively within a team
  • Sincere desire to help other people
  • Time Management
  • Attention to detail

Required Education:

  • Minimum Requirement - Utah Medical Assistant (MA) license

Experience preferred:

  • Minimum of 3+ years relevant medical records and medical terminology experience
  • Working knowledge of healthcare industry, policies, and guidelines
  • Experience working with and interpreting medical bills, statements, receipts, and medical records
  • Familiarity with HIPAA
  • Experience or familiarity in working from a CRM (Customer Relationship Management) system
  • Spanish Speaking

Physical Requirements:

  • Sit for up to 8 hours a day and look at dual computer screens
  • Type on a keyboard at a minimum of 45 WPM

Benefits:

  • Medical, dental, and vision insurance
  • 401(k) plan with company match
  • Paid time off (PTO)
  • Short-term disability insurance
  • Life Insurance
  • Paid holidays


Job Posted by ApplicantPro

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