Medical Coordinator
POSITION PURPOSE:
The Medical Coordinator reviews requests for the evaluation and authorization of medical services. The ideal candidate will be able to work independently and make judgement calls. He/she will have direct interaction with members, agents or providers and will need to become knowledgeable of policy benefits; ICD/CPT codes in order to properly evaluate cases and answer questions. The desire of providing excellent client service is a fundamental requirement of this position. The person will work under the supervision and guidance of the Medical Admin Supervisor
ESSENTIAL JOB DUTIES AND RESPONSIBILITIES:
- Acts autonomously and requests medical information for the authorization of medical services. Follows existing guidelines procedures and standards when reviewing medical cases (ICD-10, Encoder and Physicians Fee/coding guide),
- Provides explanations of benefits via phone, email and Live Chat. Gives policy benefits when required and requests necessary documentation for the evaluation of services.
- Monitor emails received in Precert inbox, ensuring that emails are answered professionally and within the established 24-48-hour time frame.
- Evaluate medical fees for cost control while following the Usual Customary and Reasonable (UCR) fee schedule and steering guidelines. Negotiate with providers and doctors if fees exceed UCR for the services described.
- Provides exceptional service while ensuring that emails are answered within 24-48 hours, service level is maintained above 90% and authorizations are issued without errors.
- Ability to work independently or as part of a team. Able to make judgement calls
- Attention to detail and ability to multi task
- Work the after-hours on call schedule as required
- Follows up on pending cases. Issues authorizations or denials as required