Job Details

Engagement Description:

• The Clinical Support Representative's primary responsibility is to facilitate and coordinate preadmission/admission reviews, prior approvals and referral requests through the medical review cycle in compliance with Rule 10, DOL (department of labor),NCQA (National Committee for Quality Assurance), and URAC (Utilization Review Accreditation Commission) timeliness requirements.
• This includes generating and performing quality assurance of correspondence, entering authorizations to ensure appropriate claims processing, and maintaining electronic medical records.
• The Clinical Support Representative is also responsible for answering department phone calls and evaluating issues and questions from internal and external customers.
• The Representative provides exceptional customer service when interacting with all internal and external customers and always maintains the highest level of confidentiality.

• Understanding of plan benefits and products
• Understanding of claims adjudication and data systems
• Understanding of medical terminology and medical coding, to include ICD-9, HCPCS, and CPT4
• Understanding of URAC, NCQA, Rule 10, DOL, and other regulatory standards pertaining to Case/Care Management