| Location | Durham, NC (Remote) |
1st preferecne - NC
100% Remote - ONLY 28 states
North Carolina, Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming will be allowed to maintain their current residence and work remotely.
Top 3-4 Required Skills: High volume experience, UM experience, strong attention to detail
Nice to have Skills: Retail Pharm Tech, Medicare Exp
Years of Experience: 3-5
Industry Specific Experience Healthcare insurance, Retail Pharmacy
What is this role s main focus for the 1st 90 days? First month is training, second month will be work done with quality checks
Breakdown of Duties/Typical Day:
They will be answering periodic calls that come through from the Tier 1 call team. They will also be working through prior authorization from faxes. They will be in a portal where they might need to reach out to memebers to inform them of being approved, not picking up medicine.
Interview Process: 2 panels - 30 minutes with Monica and Tony. 30 minute panel with Crystal and Megan.
Round 1 will be looking at it from a soft skillset and culture perspective. Round 2 will be more of a peer interview and diving deeper into the day to day work.
Description:
" Conducts non clinical reviews based on applicable criteria and guidelines on requested services. Communicates decision to provider and/or member, according to department protocols.
" Documents outcome of reviews and demonstrates the ability to interpret and analyze the non-clinical information.
" Completes verbal or non verbal outreach to providers or members to obtain the medical information for the review.
" Identifies and refers organization determinations that require a clinical review to a nurse or Medical Director.
" Conducts reviews of authorizations entered to ensure accuracy to avoid impacting claims payment.
" Supports the care management department by completing outreaches to members or providers to meet The Centers for Medicare & Medicaid Services (CMS) requirement for soliciting information or notification standards.
" Supports the administrative support team with the retrieval and attachment of facsimiles to ensure customer requests are forwarded to the respective area for processing.
" Serves as a subject matter expert for CM&O around the non-clinical review process.
Hiring Requirements
" High school diploma or GED
" 3+ years of experience in related field.