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April 18, 2019  
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PreService Assistant

Position Description

Answer difficult telephone inquiries from providers regarding the Utilization Management program. Answer Care Management telephone inquiries from Providers and member regarding Case Management and Disease Management. Reviews and communicates the physician reviewers' medical decisions for prior authorization requests to the provider and/or facilities via telephone, fax, letter and/or e-mail to all providers involved in each case. Interact daily with members, facilities and providers advising them of decisions to approve, extend, or deny services. Assist and/or perform special projects as assigned. Review and handle Customer Service and Claims issues as they pertain to the Utilization Management process. Load complete authorizations/Notifications for services designated by internal policy. Research and resolve problems with physicians, providers, and practitioners or forward to appropriate personnel for handling. Load demographic information for initial prior authorization requests. Review and handle multiple reports. (authorization error, pend, etc.) Search for and key appropriate diagnosis and/or procedure code as part of the notification/prior authorization process. Identifying and referring cases appropriately to Care Management and/or Transition of Care. Handle multiple outlook buckets assigned to department regarding authorization request/review Handle initial benefit exclusion request and generate manual letters to members, notify providers of benefit exclusion via phone/fax. Assist in Team development and Mentoring with new employee's, Maintain departmental goals and standards.

Education High School Diploma or Equivalent work experience with a minimum of 2 years medical or business experience. Experience Minimum 2 year Customer Service or Claims experience required Minimum of 1 year experience in Health Care Services specific to UM/CM preferred. Skills/Certifications Extensive knowledge of UM program including claims, correspondence, and denial/appeals process. Exceptional telephone and written communication skills. Ability to dialogue with providers and members effectively. Ability to make sound independent decisions. Ability to read and understand medical terminology Excellent organizational skills. Knowledge of medical terminology. Experience with personal computers, Word/Excel helpful but not required. Handle interruptions, set priorities, adapt to change Experience with the e-mail system, Outlook. Knowledge of ICD-9 and HCPCS/CPT coding, or knowledge of Encoder Pro Type 45 wpm. Knowledge of Filenet, Rightfax/,Member Document Management

Additional Information

Employment Type: Contractor    
Position Location: Nashville TN

Contact Information

Phone: 732-228-8622

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