Healthcare - Care Review Processor II

Will the position be 100% remote? 100% remote
Are there any specific location requirements? Bexar County San Antonio preferrably
Are there are time zone requirements? Central Standard 8-5
What are the must have requirements? Must have excel knowledge, computer skills, typing skills, must have some call skills as they will be making outbound calls to obtain physician letters
What are the day to day responsibilities? Calling MD offices, documenting in our Molina system and updating their productivity report and uploading any successful letters and advising the team for processing
Is there specific licensure is required in order to qualify for the role? No
What is the desired work hours (i.e. 8am 5pm) 8-5 CST


Summary: Works within the Care Access and Monitoring (CAM) team to provide clerical and data entry support for Molina Members that require hospitalization and/or utilization review for other healthcare services.Checks eligibility and verifies benefits, obtains and enters data into systems, processes requests, and triages members and information to the appropriate Health Care Services staff to ensure the delivery of high quality, cost-effective healthcare services according to State and Federal requirements to achieve optimal outcomes for Molina Members. Essential Functions: Provide computer entries of authorization request/provider inquiries by phone, mail, or fax.Including: oVerify member eligibility and benefits, oDetermine provider contracting status and appropriateness, oDetermine diagnosis and treatment request oAssign billing codes (ICD-9/ICD-10 and/or CPT/HCPC codes), oDetermine COB status, oVerify inpatient hospital census-admits and discharges, oPerform action required per protocol using the appropriate Database. Respond to requests for authorization of services submitted to CAM via phone, fax and mail according to Molina operational timeframes. Participates in interdepartmental integration and collaboration to enhance the continuity of care for Molina members including Behavioral Health and Long Term Care. Contact physician offices according to Department guidelines to request missing information from authorization requests or for additional information as requested by the Medical Director. Provide excellent customer service for internal and external customers. Meet department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores. Notify Care Access and Monitoring Nurses and case managers of hospital admissions and changes in member status. Meet productivity standards. Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA). Participate in Care Access and Monitoring meetings as an active member of the team. Meet attendance guidelines per Molina Healthcare policy. Follow Standards of Conduct guidelines as described in Molina Healthcare HR policy. Comply with required workplace safety standards. Knowledge/Skills/Abilities: Demonstrated ability to communicate, problem solve, and work effectively with people. Working knowledge of medical terminology and abbreviations. Ability to think analytically and to problem solve.Good communication and interpersonal/team skills. Must have a high regard for confidential information. Ability to work in a fast paced environment. Able to work independently and as part of a team. Computer skills and experienced user of Microsoft Office software. Accurate data entry at 40 WPM minimum.Required Education:High School Diploma/GEDRequired Experience:2-4 years of experience in a Utilization Review Department in a Managed Care Environment. Previous Hospital or Healthcare clerical, audit or billing experience. Experience with Medical Terminology.