Medical Authorization Coordinator
Neuron LLC
Total years of experience :12 years, 10 Months
• Assess/Process written day case and low cost inpatient pre-authorizations and communicate with clients/providers/members when required.
• Assist medical providers (hospitals/clinics/pharmacies) and clients on the pre-approval follow-up cases.
• Answer all incoming calls related to authorization following the company guidelines and protocols as per the workload.
• Manage night shift duties for IP Team with the assistance of dedicated Senior Medical Consultant.
• Answer all incoming calls related to Inpatient Authorizations following the company guidelines and protocols.
• Reviews case records and reports, collects and analyzes data, evaluates client’s medical status and defines needs and problems in order to provide proactive case management services.
• Handle incoming client/provider emails for ongoing/escalated IP cases.
• Facilitate and complete the administrative and demographic portion of the Pre-Authorization screen module for each request received from the provider/clients/members.
• Researching bill discrepancies and report non-payment issues.
• Entering and uploading details of the claims onto the operating software.
• Coordinate with the internal departments.
• Obtain medical records from providers telephonically during initial contact, and follow-up with written correspondence if necessary. Document all contacts and outcomes related to case activity in the system.
• Maintains contact and communicates with insurance companies to apprise them of case activity, case direction or receive authorization for services. Maintains contact with all parties involved on case, necessary for case management for the client.
• Facilitate case coordination and information sharing with the team members related to various medical cases.
• Work with case managers and senior medical authorization consultants who in turn will liaise with medical providers.
• Utilizing experience and medical resources interprets medical records and test results and provides assessment accordingly.
• Abide to the monthly roster for the Medical Authorization IP team, ensuring adequate staffing for all shifts as per business requirements.
• Monitor daily log sheets for the IP team to assess daily performance.
• Attend weekly meeting to delegate team task as per process requirements.
• Receive daily allocation of IP Team assignments including allocation of incoming faxes to IP team.
• Follow complaint resolution process.
• Carry through administrative tasks/duties in connection with various cases.
• To ensure that all complaints escalated from team members are resolved within 5 working days.
• Review along with the operations manager, supervisor, team leaders daily call reports to assess adherence to KPI
• Ensuring Service Level Agreements (SLA) of the client is met for based on the contractual agreement.
• Ensure the clients are provided for the accurate information by the executives.
Assess and validate the information on all the claims received.
Provide initial evaluation of claims before sending to the TPA. Keep records of all claims and correspondence.
Coordinate with TPA’s, brokers and clients for all claims related matters.
Prepares payment reports for both direct billing and reimbursement claims
Implements HAAD and DHA policies in evaluating claims and issuing approval
Respond to queries/clarifications from clients, members and TPA
Ensures all claims are settled within the agreed TAT
Serves customers by providing product and service information; resolving product, service and delivery problems.
Duties:
Establishes policies by entering client information; confirming pricing.
Keep records of customer interactions and transactions, recording details of inquiries, complaints, and comments, as well as actions taken
Confer with customers by telephone or in person in order to provide information about products and services, to take orders or cancel accounts, or to obtain details of complaints.
Resolves product or service problems by clarifying the customer's complaint; determining the cause of the problem; selecting and explaining the best solution to solve the problem; expediting correction or adjustment; following up to ensure resolution.
Coordinate deliveries with suppliers to ensure timely delivery to customers.
Provide appropriate answer to customer queries regarding our products and promotions.
Responsible to provide support and assist clinical team with the promotion of quality member outcomes, optimizing member benefits, and promoting effective use of resources. Supports the procedures that ensures the adherence with medical policy, member benefits and of providing services that are medically appropriate, high quality and cost effective.
Gathers information and conducts pre-review screening under the guidance and direction of US licensed health professionals.
Duties:
Manages incoming faxes, including triage, opening of cases and data entry into client system.
Determines contract and benefit eligibility; obtains intake (demographic) information from fax. Conducts a thorough radius search in Provider Finder and follows up with provider on referrals given; refers cases requiring clinical review to a nurse reviewer. Processes incoming requests, collection of information needed for review from providers, utilizing scripts to screen basic and complex requests for pre-certification and/or prior authorization. Verifies benefits and/or eligibility information.
Checks benefits for facility based treatment.
Review and analysis of post service claims utilizing the member’s benefit contract and health plan guidelines.
Completes review of pended claims post service utilizing client screening tools for any of the following: Medical Necessity or Contractual Reviews and submit recommendations to the client for determination.
Data entry of contact into client systems and route as appropriate
Provide administrative support to client’s Case Manager via case preparation, phone number verification, appointment scheduling calls, medical record requests
Review of received information and submits a summarization of Member’s potential care need and/or DME need following discharge and forwards to client for final discharge plan
Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.