Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life’s best work.(sm)
Under the supervision of the Medical Claims Review (MCR) Supervisor, this position is responsible for processing Utilization Management (UM) Inventory. MCR Coordinator is responsible for handling customer service or provider calls as needed. Coordinates UM processes with WellMed Medical Directors, UM Nurses, hospitals, physicians and other various departments. MCR Coordinator is responsible for providing clerical support to WellMed clinical staff for their medical necessity review process. MCR Coordinator is expected to maintain production and quality standards.
- Research and resolve UM inventory accordingly to meet productivity and quality standards to include:
- Claims reports with reconciliation needs
- Information received through Right Fax
- Information received through email
- Or any other methods of receipt (phone calls, etc.)
- Coordinates initial screening for UM claim reviews through claim queue
- Prepares administrative files for Medical Directors, UM Nurses and Case Managers
- Contacts provider offices to obtain clinical information for medical review by a clinician to meet Center for Medicare and Medicaid Services (CMS), state and health plan guidelines/regulations.
- Documents and follows-up on all assigned inventory, utilizing on-line systems and procedures, according to established guidelines
- Maintains knowledge of various health plan partner benefits, networks, CMS regulations and health plan partner policies
- Utilize experience and judgement to plan, accomplish goals and effectively resolve each assigned task
- Receives and responds to telephone calls through the UM Phone Queue, as needed
- Performs all other related duties as assigned
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
- High School Diploma or GED equivalent
- Two or more years managed care experience in Prior Authorization or Claim Review
- Medical Terminology, ICD-9/ICD-10 and CPT knowledge
- Proficient with Medicare processing guidelines, working knowledge of medical contracts
- Exceptional ability to organize, prioritize and communicate effectively.
- Proficiency with Microsoft Office applications, i.e. Excel, Access
- Ability to provide excellent customer service to a varied customer base
- Ability to navigate multiple systems
- Ability to work in a fast-paced environment
- You will be provisioned with appropriate Personal Protective Equipment (PPE) and are required to perform this role with patients and members on site, as this is an essential function of this role
- Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained
- Associate’s Degree in a healthcare related field
Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 380,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi - specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Job Keywords: Medical Claims Review Coordinator, San Antonio, TX, Texas