HEDIS Role

Job Summary:

This position supports the Health Services and Utilization Management functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators.

Responsibilities: -

• Performs review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients.
• Handles initial screening for pre-certification requests from physicians/members via incoming calls or correspondence based on scripts and workflows, and under the oversight of clinical staff.
• Prepare, document and route cases in appropriate system for clinical review.
• Initiates call backs and correspondence to members and providers to coordinate and clarify benefits.
• Upon completion of inquiries initiate call back or correspondence to Physicians/Members to coordinate/clarify case completion.
• Reviewing professional medical/claim policy related issues or claims in pending status.
• Upon collection of clinical and non-clinical information MCC can authorize services based upon scripts or algorithms used for pre-review screening.
• Non Clinical staff members are not responsible for conducting any UM review activities that require interpretation of clinical information.
• Perform other relevant tasks as assigned by Management.

Core Individual Contributor Competencies:

• Personal and professional attributes that are critical to successful performance for Individual Contributors: Customer Focus Accountable Learn Communicate

Qualifications:

Education: -

• High School Diploma required. Some College preferred.

Work experience: -

• Prefer 1-2 years customer service or medical support related position.

Specialized knowledge/skills: -

• Requires knowledge of medical terminology
• Requires Good Oral and Written Communication skills
• Requires ability to make sound decisions under the direction of Supervisor
• Prefer knowledge of contracts, enrollment, billing & claims coding/processing
• Prefer knowledge Managed Care principles
• Prefer the ability to analyze and resolve problems with minimal supervision
• Prefer the ability to use a personal computer and applicable software and systems
• Team Player, Strong Analytical, Interpersonal Skills