Description
Job Description
Position Title: Managed Care Coordinator
Job Code: K1602
Department/Cost Center(s):
Case Management/8756
Position Summary:
The individual in this position works under direction of the Director of Case Management and coordinates utilization reviews of managed care contracts using established guidelines and processes. Ensures all clinical operations comply with Medicare and Medicaid guidelines and other managed care policies.
Essential Duties:
1. Responsible for complete and accurate data integrity and quality of files.
2. Takes initiative to improve services to both external customers and personal productivity through continuous enhancement of systems, programs and products.
3. Is responsible for verifying member's eligibility and interpreting benefit levels capitated plans.
4. Documents disputes in DCM, write appeal letters, follow-up on appeals as needed.
5. Has thorough understanding of the duties/specifics to utilization and demonstrates flexibility in carrying out those duties as needed.
6. Compiling and or analyzing of department specific reports i.e. Monthly Dispute report, UM Committee quarterly reports, and other reports as requested..
7. Maintain front end QC process pertaining to authorizations, clinical reviews needed and accurate payer information.
8. Maintains managed care contracts and information databases and prepares reports.
9. Acts as resource to case managers, payers, physician's office staff and plan hospitals in dealing with utilization issues (eligibility verification, benefit interpretation, and copayment information).
10. Must perform clinical reviews using InterQual criteria and/or clinical review based on insurance requirements using the EMR and Allscripts.
11. Performs all other duties as assigned.
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