Position Summary:
Under the direction of the Supervisor, Patient Care Management functions in the intake area. Responsible for intake specialist duties, Durable Medical Equipment responsibilities, as well as assisting with the orientation and training of intake specialists.
Principal Accountabilities:
1. Under the direction of the supervisor, assists in training, educating and guiding the development of new and existing intake specialists and Durable medical equipment specialists.
2. Adheres to Standard Operating Procedures, Process Standards and Policies and Procedures.
3. Utilizes and has knowledge of phone / service level requirements for compliance with governing bodies and standards.
4. Performs intake functions to meet real time, or as near to real time as possible, standards for departmental operations.
5. Responsible for pre-certification and recertification process for Durable Medical Equipment and selected outpatient therapies.
6. Interacts with internal and external customers in a real time manner to promote quality and excellent customer service.
7. Authorizes services based on Health Plan Guidelines. If unable to approve, submits the request to Health Plan Medical Director for medical necessity determination.
8. Receives information about care delivery service to members via facsimile, telephone, or letter. Create new member specific case in software program when indicated. Document information in software program.
9. Completes detail lines in MEDecision to reflect authorization or denial of services.
10. Verifies and documents member eligibility.
11. Routes case to appropriate Clinical Coordinators, Case Managers, DME specialists for continuation of medical necessity review process.
12. Communicates case specific information as indicated to Health Plan providers. Information includes, but is not limited to member identification number, provider identification number, Health Plan personnel/departmental telephone numbers, and case reference number.
13. Maintains professional, customer service focused demeanor in telephonic interactions with providers.
14. Meets individual required goals and contributes to the departmental service level standards for : Average speed of answer, Call abandon rate, Average hold time
15. Maintains a current knowledge base of computers and systems, and participates in learning and applying updates and changes.
16. Documents compliance with prior authorization process, Policy and Procedures.
17. Participates in Quality Reviews and Timeliness studies and achieves performance results at or above thresholds established by management.
18. Delivers customer service in a professional manner in all contacts.
19. Performs other related duties and projects as assigned.
20. Adheres to Health Plan s Policies and Procedures.
21. Supports and carries out the Mercy Mission and Values.
22. Complies with Health Plan, DPW and HIPAA confidentiality requirements protecting member personal identifiable health information.