Clinical Resources Intake Coordinator I

Summary Description:

The Clinical Resources Intake Coordinator I is responsible for processing and coordinating phone and fax authorization requests for medical services from physicians and hospitals (providers) and screening of case management referrals to determine appropriateness for case management services. This position is expected to adequately capture patient information to allow for a clinical review for authorization determinations. The Clinical Resources Intake Coordinator I prepares, tracks, and closes all Clinical Resources (CR) case files in coordination with the Utilization Management (UM). The Clinical Resource Intake Coordinator I is responsible for timely notification to members and providers of all Clinical Resource decisions, triaging phone calls transferred by Member Services, and assisting other departments with authorization related questions. The Clinical Resources Intake Coordinator I also provides administrative support for the Clinical Resources team by coordinating services, record retention, as well as other administrative functions. The Clinical Resources Intake Coordinator I also assists in completing activities related to various cross-functional projects in support of departmental goals.

Representative Duties:

• Retrieve, coordinate and triage incoming authorization requests, documentation, and medical records related to out-of-area (OOA) emergency room (ER), inpatient admissions, continuity of care (COC), clinical trials, experimental procedures, , second opinions, prior authorizations, durable medical equipment (DME), transgender surgery and transplant requests.

• Identify responsible party for all OOA ER and inpatient admissions by verifying the member’s eligibility, contacting the Medical Group, verifying if patient remains admitted, communicating with clinical staff and creating authorization tracking case.

• Receive and triage calls from members and providers regarding OOA services that are received directly or transferred by Member Services; collect necessary information and coordinate with clinical staff to assist and educate the member or provider.

• Log all authorization requests per current procedures, create authorization tracking case, document actions and communicate with clinical staff.

• Ensure timely notification of authorization request decisions on all Clinical Resource cases Authorization Requests to members and providers/Medical Groups, document notification activities and update the appropriate log.

• Monitor pending cases to ensure timely completion and notification.

• Provide assistance and education to department staff, Case Management/Utilization Management contacts for contracted providers and various network/non-network providers, facilities, and vendors.

• Coordinate with Member Relations to ensure completion of appeal overturn decisions as needed.

• Assist Member Services with complicated authorizations, OOA.

• Assist Claims in researching and reviewing claims and authorization issues.

• Primary point of contact for receiving phone calls to the Clinical Resources staff.

• Assist clinical staff in obtaining necessary information from providers.

• Perform other duties and special projects as assigned

Qualifications:

• High School Diploma.

• 1 year experience working in a similar role in the health care industry; preferably HMO.

• Intermediate computer skills, including electronic mail, routine database activity, word processing, spreadsheet, graphics, etc.

• Must be able to speak, read, write, and understand the primary language(s) used in the workplace.

Salary:

$20.00-$22.00 hourly

Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law. (EOE)

Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you — and excellent customer service for our members.

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