Job Description:
• Provide timely referral/appeal determination by accurate
• Work under the usage of the Milliman Care Guidelines and or Interqual
• Select appropriate letter language to author appeal letter
• Identification of referrals to the medical director for review
• Select appropriate preferred and contracted providers
• Provide proper identification of eligibility and healthcare plans
• Maintain compliance in turnaround time requirements as mandated by the TAT Standards of the facility and/or CIOX Health Standards
• Work directly with the provider(s) and health plan Medical Director as needed to facilitate timely authorizations and/or denial reversals
• Maintain and keeps in total confidence, all files, documents and records
• Meets or exceeds production and quality metrics
• Attend all mandatory meetings and trainings
Requirements:
• Two (2) years managed care experience in UM/CM/CDI Department preferred
• Knowledge of CMS, State Regulations, URAC and NCQA preferred
• ICD10 and CPT coding a plus
• Experienced computer skills, Word, Excel, Outlook, experience working in a health plan medical management documentation system a plus.
Benefits:
• Health insurance
• Flexible work hours
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