Northpointe Staffing Professionals

*Remote role but requires travel to Hopewell at least once a month*

This position supports the Health Services and Utilization Management functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators.
Responsibilities:

·       Performs review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients.

·       Handles initial screening for pre-certification requests from physicians/members via incoming calls or correspondence based on scripts and workflows, and under the oversight of clinical staff.

·       Prepare, document and route cases in appropriate system for clinical review.

·       Initiates call backs and correspondence to members and providers to coordinate and clarify benefits.

·       Upon completion of inquiries initiate call back or correspondence to Physicians/Members to coordinate/clarify case completion.

·       Reviewing professional medical/claim policy related issues or claims in pending status.

·       Upon collection of clinical and non-clinical information MCC can authorize services based upon scripts or algorithms used for pre-review screening

·       Perform other relevant tasks as assigned by Management.

Qualifications:

·       Education: - High School Diploma required. Some College preferred.

·       Prefer 1-2 years customer service or medical support related position.

·       Requires knowledge of medical terminology

·       Requires Good Oral and Written Communication skills

·       Requires ability to make sound decisions under the direction of Supervisor

·       Prefer knowledge of contracts, enrollment, billing & claims coding/processing

·       Prefer knowledge Managed Care principles

·       Prefer the ability to analyze and resolve problems with minimal supervision

·       Prefer the ability to use a personal computer and applicable software and systems

·       Team Player, Strong Analytical, Interpersonal Skills