Broadview, Illinois, United States
Talented Intake Specialist offering 3 years of experience in conducting intake interviews and summarizing data with speed and efficiency. Connects with clients easily to provide thoughtful and compassionate assistance. Manages client files and prioritizing tasks to achieve optimal productivity.
Provide internal support to the medical management department by ensuring all services referred meet plan requirements. Responds to all incoming calls from PCP, specialist, and other providers regarding surgeries, inpatient and outpatient services including DME, home healthcare and other services requiring prior authorization. Understand health plan policies and procedures regarding pre authorization, benefits by health plan and preferred facilities within each plan. Data entry of inpatient admissions, including elective admissions with a surgical component. Maintain compliance and remain within turn around time with all health plan guideline and referrals. Lead the implementation of new processes with new HMO groups. Apply MCG guidelines and BCBS medical policy to approve referrals for DME and outpatient services.
Answer questions from members clerical staff and insurance companies. Identifies and resolves patient billing problems and complaints. Handles customer collection calls. Documents activities in ERP system in an efficient, accurate, and timely manner. Evaluate and secure RX's, prior authorizations and medical justification to facilitate payment of claims. Edit and resubmit claims for payment. Prepare and review clean claims for submission to various insurances either electronically or paper. Knowledge of medical terminology and insurances HCPC/ICD-9 codes
Audit cases to ensure compliance is being maintained daily. Create daily out of compliance report. Audit new associates in training. Update director with work trends pertaining to associates' compliance metrics. Listen to associate calls to ensure quality standards are met. Monitor associates activity for productivity purposes. Test new processes for development purposes. Coordinate training for new associates and compose training materials. Create and operate new department improvement projects. Complete new associate onboarding. Document and process workflows. Prepare management reports daily, weekly, and monthly. Referral Coordinator Associate Review, proofread, and approve all cases that are pending closure Verbally notify ordering physicians of the determination, when applicable Close cases according to health plan specific date and time Perform quality checks to ensure compliance Search database and provide documentation assistance to physicians Answers questions from customers, clerical staff, and ordering providers. Provides feedback to Team Leads regarding issues regarding patient accounts. Working knowledge of medical terminology and insurances such as ICD-9 codes Working knowledge of Medicare, Medicaid and government programs. Verifies insurance coverage, and completed preauthorization request Resolves members inquires including data entry, processing, and providing status updates. Initiate the process of preauthorization request for outpatient and inpatient services and routing to the appropriate staff. Worked with insurance payers and billing to determine the method of payment for patients. Manage financial and medical records Manage and adjust claims Process appeals Processed letters, forms, and other documents. Reviewed internal documents for accuracy and completion. Organized files and documents to be assigned to associates Fax letters to doctors’ offices Organize, compose, review, and send documents within the company as needed.