Healthcare Services Program Specialist

4 weeks ago

Austin, United States Central Health Full time
Overview

Works within the Medical Management team to provide clerical and data entry support for members that require hospitalization and/or utilization review for other healthcare services. The Program Specialist is responsible for building authorizations in the Medical Management department and reports to the Supervisor of Program Specialists. The Program Specialist is also responsible for a variety of tasks associated with the authorization process including, but not limited to monitoring of intake modes (fax and web portal), creating the authorization request in the system, ensuring required documents are attached, answering calls from and placing calls to providers, creating decision/outcome letters including appeal resolution letters, and mailing of correspondence to ensure the delivery of integrated high quality, cost-effective healthcare services according to State and Federal requirements to achieve optimal outcomes for Members. Hours of operation are Monday through Friday 8 am to 5 pm to include extended hours that may occur on a weekends and/or holidays as required by State and Federal regulations in order to maintain operational compliance.

Responsibilities
  • Provide computer entries of authorization request/provider inquiries by phone, mail, or fax. Including: 
    • Verify member eligibility and benefits, 
    • Determine provider contracting status and appropriateness, 
    • Determine diagnosis and treatment request
    • Assign billing codes (ICD-9/ICD-10 and/or CPT/HCPC codes), 
    • Determine COB status, 
    • Verify inpatient hospital census-admits and discharges,
    • Perform action required per protocol using the appropriate Database.
  • Supports the Medical Management department via clerical and data entry support for members that require hospitalization and/or utilization review for other health services.
  • Checks eligibility ad verifies benefits, obtains and enters data into systems, processes requests, and triages members and information to the appropriate staff to ensure the delivery of integrated high quality, cost-effective healthcare services in accordance to State and Federal requirements to achieve optimal outcomes for members.
  • Answering or calling providers to provide information on the prior authorization process including whether prior authorization is required, advising on information needed for prior authorization request, as well as status of the prior authorization.
  • Mailing authorization determination letters to members and / or providers.
  • Fax to providers request for information or determinations.
  • Notify nurses and case managers of hospital admissions and changes in member status.
  • Deliver outstanding customer service to both internal and external clients.
  • Meet department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores.
  • Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
  • Participate in Medical Management meetings as an active member of the team.
  • Ensure adherence to Sender's policies and procedures as well as TDI/NCQA guidelines.
Knowledge/Skills/Abilities:
  • Demonstrated ability to communicate, problem solve, and work effectively with people.
  • Working knowledge of medical terminology and abbreviations.
  • Ability to think analytically and problem solve.
  • Good communication and interpersonal/team skills.
  • Ability to work in a fast paced environment.
  • Able to work independently and as part of a team.
  • Computer skills and experienced user of Microsoft Office software.
  • Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.
  • Computer skills and experience with Microsoft Office Products.
  • Knowledge of office equipment and procedures.
  • Flexibility, willingness to learn new responsibilities.
  • Willingness to work in a constantly changing environment.
Qualifications

EDUCATION: 

  • Associate's Degree in Business, Health, or related field -OR- High School Diploma or equivalent with 4 additional years of experience in healthcare industry in lieu of degree required.

EXPERIENCE: 

  • 4 years of experience in healthcare industry required.
  • Spanish-speaking preferred.

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