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Medical Management Coordinator-Government Programs

Company

Blue Cross and Blue Shield of Kansas City
Address United States
Employment type FULL_TIME
Salary
Category Insurance
Expires 2023-05-25
Posted at 1 year ago
Job Description
Some Of Our Offerings Include


Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience.
  • Competitive benefits package with day one eligibility
  • Professional development courses, mentorship opportunities and tuition reimbursement program
  • Paid parental leave and adoption leave with adoption financial assistance
  • Time away from work including paid holidays, paid time off and volunteer time off
  • Employee discount program
  • Annual employee bonus program to reward success
  • Employer covers 90% of monthly premium cost for health, dental and vision plans
  • Robust 401(k) with 50% match and end of year discretionary employer contribution
Summary
Provides information management services to the Medical Management Department by researching and reviewing claims; resolving customer service problems; and triaging and indexing all medical records. Also assists with the substantive work of the Medical Management department, including making determinations on prior authorization issues not requiring clinical review.

  • Researches, reviews and resolves claims and benefit questions with Customer Service and other Operations areas. Regularly converses by phone with members and providers, either directly or as transferred by customer service representatives.
  • Receives faxed information via document imaging system for inpatient admissions, outpatient services, DME, and post service medical review. Responsible for indexing, triaging and data entry into Facets.
  • Documents in a computerized tracking system.
  • Receives pre-service review requests telephonically in a call center environment for inpatient, outpatient or DME requests.
  • Other duties as assigned
  • Performs all duties in a manner consistent with the company’s Code of Conduct and policies and procedures and other related duties as assigned to meet departmental and company objectives.
  • Reviews requests using a defined, approved script. Determines appropriateness of request, or, as necessary, refers to clinical staff for review and certification of medical appropriateness. Generates letters of acceptance in FACETS to members and providers or makes non-clinical contract denial decisions (clinical denial decisions are made by a Medical Director). Contacts providers with determinations and if appropriate provides appeals information and generates letters.
Minimum Qualifications
  • Ability to effectively present information in one-on-one and small group situations to customers, clients, groups of managers, and other employees of the organization.
  • Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
  • Experience researching, summarizing, and communicating detailed information and analysis
  • Ability to define problems, collect data, establish facts and draw valid conclusions.
  • Associate’s degree from a college or university in business administration, health care management, or other relevant academic field or a High School diploma and 2 years of experience in positions providing intimate familiarity with medical terms.
  • Ability to write reports, business correspondence, and procedure manuals.
Preferred Qualifications
  • Other specialized knowledge and skills preferred include HIPAA requirements; UM denial/appeals specifications; NCQA, URAC, and state and federal UM requirements.
  • Intermediate knowledge of and ability to use Microsoft Office applications.
  • Advanced keyboarding skills.