Description |
Job Description
SUMMARY
To review requests for pre-certification of services, obtain further information if needed, approve requests, and send potential denials to medical director for further action.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following & other duties that may be assigned.
Reviews requests for services that require pre-certification, such as treatment by non-participating providers, hospitalization, certain outpatient procedures and surgery, as well as DMEPOS, outpatient therapy and rehabilitation programs.
Contacts patients or physicians as appropriate to obtain information and asks questions when additional detail is necessary to certify medical necessity.
Reviews particular plan coverage to make sure patient is entitled to requested services.
Approves requests that fulfill plan guidelines. Notifies providers and patients of approval as appropriate.
Forwards potential denials to Medical Director for further review and decision by supervisor or medical team.
Answers telephone requests from MD/Members and providers offices about pending organization determinations.
Maintains open channels of communication with other company departments. Answers all inquiries in a professional and courteous manner.
Complies with Leon Medical Centers Health Plans, Inc.s policies and procedures and maintains confidentiality of member information in accordance with state and federal laws.
Participates in training and in-service education as required.
Participates in department and clinic meetings as requested.
Performs other related duties assigned.
QUALIFICATIONS
RN or LPN with current Florida nursing license with 3-5 years acute care experience.
or
Foreign Medical Graduate with proper documentation of medical training and/or experience with a minimum of 1-2 years managed care experience in utilization review or case management.
Two or more years of experience in an office setting, with customer service and computer skills.
Hospital or clinic experience, or training in medical terminology preferred.
Ability to work effectively in a team environment.
Must have excellent interpersonal skills.
Work time is approximate. Hours and days are changed according to company needs. All full-time employees are required to complete their 40 hours per week schedule.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
KNOWLEDGE, SKILLS AND ABILITIES- Fluent in English and Spanish required.
CERTIFICATES, LICENSES, REGISTRATIONS- Up to date and in accordance with state legislation.
PHYSICAL DEMANDS/WORK ENVIRONMENT The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This work requires the following physical activities: climbing, bending, stooping, kneeling, twisting, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors..
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Requirements |
See job description.
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