Care Review Processor

Care Review Processor I (TEMP)
Location:	OH-Columbus (MHO COLUMBUS)
ID:	5769
# of Openings:	4
Description
JOB 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 including Behavioral Health and Long Term Care.  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 integrated high quality, cost-effective healthcare services according to State and Federal requirements to achieve optimal outcomes for Molina Members.   DUTIES AND RESPONSIBILITIES • Provide computer entries of authorization request/provider inquiries by phone, mail, or fax.  Including: Verify member eligibility and benefits, Determine provider contracting status and appropriateness, Determine diagnosis and treatment request Determine COB status, Verify inpatient hospital census-admits and discharges Perform action required per protocol using the appropriate Database • Meet department productivity standards. • Respond to requests for authorization of services submitted to CAM via phone, fax and mail according to Molina operational timeframes. • 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. • 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.   STATE PLAN/DEPARTMENT SPECIFIC DUTIES AND RESPONSIBILITIES Responsible for eligibility and benefit verification and collection of medical data needed to create authorizations and approve designated services.  Coordinates the review and approval process for inpatient and outpatient hospital services, ambulatory medical imaging, diagnostic testing, durable medical equipment, home health care, and high cost injectable drugs.  Functions as a resource for other licensed and non-licensed UM staff.  Assists the Care Coordination team in delivery of high quality, cost effective health care services for Molina members.  Cross- trained to support the other functions performed by the Welcome Team – incoming phone queue, fax triage (UMK2), and handling of incoming and outgoing mail.   KNOWLEDGE, SKILLS AND 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.     QUALIFICATIONS Required Education  • High School Diploma/GED                                                                                                              Preferred Education • Associates in Arts degree or other degree   Required Experience      • Previous Hospital or Healthcare clerical or billing experience         Preferred Experience • One year or more in a Managed Care Environment • Hospital billing or coding                                                                                                                                Preferred Licensure/Certification • Certified Clinical Coder   To all current Molina employees if you are interested in applying for this position please fill out an Employee Transfer Request Form (ETR) and attach it to your profile when applying online.  Be sure to let us know you are a current employee by selecting “Molina Employee (current) in the source section of the online application. Molina Healthcare offers competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V   apply here