[Hiring] Healthcare – Care Review Processor I @Molina

Role Description

Works within the Care Access and Monitoring (CAM) team to provide clerical and data entry support for Molina Members that require hospitalization and/or utilization review for other healthcare services.

• Checks eligibility and verifies benefits
• Obtains and enters data into systems
• Processes requests and triages members and information to the appropriate Health Care Services staff
• Ensures the delivery of high quality, cost-effective healthcare services according to State and Federal requirements
• 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
• Respond to requests for authorization of services submitted to CAM via phone, fax and mail according to Molina operational timeframes
• Participates in interdepartmental integration and collaboration to enhance the continuity of care for Molina members including Behavioral Health and Long Term Care
• Contact physician offices according to Department guidelines to request missing information from authorization requests or for additional information as requested by the Medical Director
• Provide excellent customer service for internal and external customers
• Meet department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores
• Notify Care Access and Monitoring Nurses and case managers of hospital admissions and changes in member status
• Meet productivity standards
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
• Participate in Care Access and Monitoring meetings as an active member of the team
• Meet attendance guidelines per Molina Healthcare policy
• Follow Standards of Conduct guidelines as described in Molina Healthcare HR policy
• Comply with required workplace safety standards

Qualifications

• Some knowledge of healthcare
• Previous phone queue experience
• Fast learner
• Able to work independently
• Previous remote working experience
• Knowledge of Microsoft Office products

Requirements

• High school diploma
• Medical Assistant certification if possible
• 1-2 years of experience in a Utilization Review Department in a Managed Care Environment
• Previous Hospital or Healthcare clerical, audit or billing experience
• Experience with Medical Terminology

Benefits

• Potential for this role to extend past 6 months and/or convert to an FTE