Job Description :
- Receive, review and make determinations regarding physician reviewer assignments for medical management decisions. Cases requiring physician review are provider and member requests, received from Medical Management & Policy (MM&P) and Member Grievance Departments.
- Responsible for management of Peer to Peer telephone line. Will handle calls in accordance with regulatory requirements.
- The timely assignment of cases in accordance with regulatory agencies’ standards including the National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Committee (URAC), Pennsylvania Department of Health, Department of Labor, the Center for Medicare and Medicaid Services (CMS) and state specific regulations.
- Efficient communication and follow up with internal and external providers and contracted vendors.
Essential Job Functions:
1. Responsible for the timely receipt, review and assignment of all incoming physician reviewer referrals and appeals to ensure that NCQA, URAC, CMS, DOH, DOL and state specific regulatory compliance standards are met. (40%)
2. Responsible for the timely and efficient management of the physician peer to peer telephone line, including follow up with providers and provider office staffs to clarify and request information and provide follow up as necessary.The management of the peer to peer telephone lines includes:
- the timely, accurate assignment of requests to internal physician reviewers/medical directors
- the timely, accurate entry of requests into the database for reporting purposes (20%)
3. Responsible to efficiently coordinate the clinical review process with contracted external review companies in accordance with all regulatory guidelines. This includes:
- the submission and receipt of clinical information
- effective communication with the external review liaison to address questions or issues
- the efficient and accurate recording of all case information submitted for external review (20%)
4. Responsible for the timely sorting and filing of all required case information. (10%)
5. Responsible for data entry, maintenance and integrity of all databases. (10%)
6. Other duties as assigned or requested.
- High School Diploma / GED
- 3 – 5 years of related, progressive experience. Grandfathered experience requirements effective August 2016.
- Experience in navigating managed care system
- Certification or equivalent training in Word Processing, Database Management or Medical Terminology
- 1+ years of Customer Service related experience
Referral Bonus: Level 1
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