2-4 years of experience in a Utilization Review department within a Managed Care environment
Previous hospital or healthcare clerical, audit, or billing experience and familiarity with medical terminology
Strong customer service and communication skills with the ability to work independently and in a team; high regard for confidentiality
High School Diploma/GED with proficient Microsoft Office skills and accurate data entry at 40 WPM
Requirements:
Process and enter authorization requests and provider inquiries via phone, mail, or fax, including verifying member eligibility/benefits, determining provider contracting status and appropriateness, identifying diagnosis/treatment requests, assigning ICD-9/ICD-10 and CPT/HCPCS codes, verifying COB status, and tracking inpatient census/admissions and discharges per protocol in the designated database
Respond to authorization requests for services submitted to Care Access and Monitoring (CAM) within Molina's operational timeframes while delivering excellent customer service; this is a 100% remote position requiring residency in California
Collaborate with Care Access and Monitoring and related departments (e.g., Behavioral Health, Long Term Care) to improve continuity of care and communicate missing information as requested by the Medical Director
Maintain confidentiality and comply with HIPAA, meet productivity and quality standards, participate in team meetings, and adhere to Molina's Standards of Conduct and workplace safety policies
Job description
100% remote but must live in CA
schedule Monday to Friday 8:30-5:30 PST
will be a part of the phones team
needs to have strong customer service experience
requires dual monitors and a docking station
Summary: Works within the Care Access and Monitoring (CAM) team to provide clerical and data entry support for Molina Members that require hospitalization and/or utilization review for other healthcare services. Checks eligibility and verifies benefits, obtains and enters data into systems, processes requests, and triages members and information to the appropriate Health Care Services staff to ensure the delivery of high quality, cost-effective healthcare services according to State and Federal requirements to achieve optimal outcomes for Molina Members. Essential Functions: Provide computer entries of authorization request/provider inquiries by phone, mail, or fax. Including: o Verify member eligibility and benefits, o Determine provider contracting status and appropriateness, o Determine diagnosis and treatment request o Assign billing codes (ICD-9/ICD-10 and/or CPT/HCPC codes), o Determine COB status, o Verify inpatient hospital census-admits and discharges, o Perform action required per protocol using the appropriate Database. Respond to requests for authorization of services submitted to CAM via phone, fax and mail according to Molina operational timeframes. Participates in interdepartmental integration and collaboration to enhance the continuity of care for Molina members including Behavioral Health and Long Term Care. Contact physician offices according to Department guidelines to request missing information from authorization requests or for additional information as requested by the Medical Director. Provide excellent customer service for internal and external customers. Meet department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores. Notify Care Access and Monitoring Nurses and case managers of hospital admissions and changes in member status. Meet productivity standards. Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA). Participate in Care Access and Monitoring meetings as an active member of the team. Meet attendance guidelines per Molina Healthcare policy. Follow Standards of Conduct guidelines as described in Molina Healthcare HR policy. Comply with required workplace safety standards. Knowledge/Skills/Abilities: Demonstrated ability to communicate, problem solve, and work effectively with people. Working knowledge of medical terminology and abbreviations. Ability to think analytically and to problem solve. Good communication and interpersonal/team skills. Must have a high regard for confidential information. Ability to work in a fast paced environment. Able to work independently and as part of a team. Computer skills and experienced user of Microsoft Office software. Accurate data entry at 40 WPM minimum. Required Education: High School Diploma/GED Required Experience: 2-4 years of experience in a Utilization Review Department in a Managed Care Environment. Previous Hospital or Healthcare clerical, audit or billing experience. Experience with Medical Terminology.
