Provide thorough analysis and investigation of authorization requests for specialized medical/surgical/outpatient procedures in an expeditious and accurate manner ensuring provider, hospital/facility, Primary Care Group (PCG), and member quality customer service. Provide information and assistance pertaining to the Medical Management program to providers, hospitals, PCGs and members.
Assess and investigate requests for medical service authorization and authorize select services that do not require clinical judgment. Collect and record appropriate data in order to issue authorization and route request for services that require medical review to appropriate team member(s). .
Facilitate communication with providers regarding status on authorizations and referrals. Identify relevant issues and route to appropriate department for action and resolution.
Perform departmental functions such as: data preparation/presentation, interaction with internal and external sources to resolve inquires, assist with on-the-job training of new employees as requested, educate and direct providers on medical management policy, procedures, plan benefits and co-pays for all products.
Promote and engage in positive and constructive daily team interactions.
Perform other duties as assigned.
Associate’s Degree in Health Care Administration or other health related field or two (2) years full-time college credits preferred.
Current Michigan licensed LPN, RHIT (Registered Health Information Technician) or Certified Medical Assistant designation preferred.
Validated successful completion of medical terminology course required. Completion of a medical terminology course at an accredited college or career school is preferred.
College level course work in anatomy and physiology preferred.
One (1) year experience in a clinical or health insurance setting and one (1) year experience in customer service required. Customer and telephonic servicing techniques required.
One (1) year experience with ICD10, HCPCS and CPT coding preferred.
Knowledge of managed care philosophy, policies and procedures preferred.
Knowledge of BCN/BCBSM policies, procedures, and benefits preferred.
Demonstrated good verbal and written communication.
Time management, analytical, and problem solving skills in order to service providers, facilities, members and internal departments. Must be able to multi-task; organized self-starter with the ability to prioritize.
Knowledge of current standard personal computer operations required.
Data entry skills at 80-85 net key strokes per minute, with 80% accuracy required.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.