High School diploma or GED required., 1 to 3 years of experience in an administrative support role, preferably in Utilization Management or Appeals., Understanding of medical terminology, including ICD-10 and CPT-4 codes, is preferred., Call center or customer service experience is preferred..
Key responsibilities:
Receive and process service requests from providers and members via various communication channels.
Provide superior customer service and strive for first-call resolution for all inquiries.
Document and enter data accurately in the IT system related to member services and eligibility.
Assist in generating approval and denial letters, and participate in departmental quality improvement activities.
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Since 1985, MetroPlusHealth has helped the people of New York City get quality health care at little to no cost. MetroPlusHealth is the plan of choice for over 712,000 New Yorkers, and its commercial and government-sponsored plans meet the needs of individuals, families, and workforces. The MetroPlusHealth staff speaks more than 40 languages and is as diverse as the great City it serves. MetroPlusHealth is part of NYC Health + Hospitals, the nation's largest public health system. For more information, visit metroplus.org. Join the conversation on social media at @metroplushealth.
Our Mission: We provide a caring, high-quality customer experience to preserve and improve the health and lives of New Yorkers with our integrated healthcare system.
Our Vision: To be the number one plan of choice for the communities we serve.
Our Core Values: Be caring and compassionate to all
Be customer-powered: Align daily actions to positive, impactful customer experiences; connect with internal and external customers
Be proud of what we do: Take ownership and accountability; be solutions driven
Act as a team: Build trust, empower others, and champion transparent communication
Thrive with change: Spark and support innovation, and transform our business through technology and data
MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.
About NYC Health + Hospitals
MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
Position Overview
The Care Management Associate I (CMA), under the direction of the Vice President of Clinical Services, is responsible for the daily activities of member case intake, processing functions, and associated workflow, as well as for performing other duties associated with the coordination of member care as outlined and/or assigned by their manager.
Job Description
Receive service requests from providers and members via facsimile, provider portal, phone, and mail
Receive in-coming calls, address the caller’s needs (providers and members) and/or offer clarification on questions or concerns as related to policy & procedure and benefits
Strive to provide first-call resolution to all callers
Provide superior customer service to all providers and members
Verify member eligibility and benefits utilizing the IT system and/or ePACES.
Create and/or complete an authorization shell, generating a reference number.
Follow documented process flow and job aids to either process the authorization request to completion or direct request to clinical staff (Nurse or MD) for review:
Initiate requests via phone/facsimile for supporting documentation to determine medical necessity of requested services
Receive and process inbound correspondence to ensure it is associated with the correct member and contains adequate information for clinical review
Refer to RN or MD as indicated
Generate denial letters which relate to the member’s ineligibility for services when appropriate
Follow guidelines for services which can be approved by the CMA under the direction of the Medical Director
Generate approval letters for members and providers, where applicable, utilizing the system’s correspondence module, and selecting the correct letter template according to the members line of business.
Accurately document and enter data in IT system pertaining to the services requested, including correct member, provider, and clinical information such as service dates, diagnosis codes, service codes
Work efficiently and diligently and meet minimal required performance expectations and quality requirements
Assist co-workers and other staff as directed.
Participate in special projects as requested or required.
Participate in on-going training and staff meetings to enhance job knowledge and skills, and to offer ideas towards the enhancement of the department’s processes.
Participate in departmental quality improvement activities.
Perform other duties as assigned.
Minimum Qualifications
High School diploma or GED (General Equivalency Diploma)
1 to 3 years of experience in an administrative support role in either Utilization Management or Appeals
Understanding of medical terminology including ICD-10 and CPT-4 codes preferred
Call center or Customer Service experience preferred
Professional Competencies
Integrity and Trust
Customer Focus
Functional/Technical Skills
Written/Oral Communications
Strong work ethic
Efficiency and attention to detail
Ability to research on the Internet
Ability to communicate in English clearly
Proficiency in using a computer
#mph50
Required profile
Experience
Spoken language(s):
English
Check out the description to know which languages are mandatory.