Communicate via the phone (placing and receiving phone calls) as necessary.
Obtain additional information as needed from the requestor or other providers in accordance with department processes.
Process requests based on the members primary or secondary insurance as appropriate in accordance with department policies, procedures, and timelines.
Respond to inquiries in a timely manner.
Responsible for consistently meeting production and quality standards.
Document information received and action taken according to the department’s documentation standards.
Upon the completion of requests, organize and review documents to ensure all required information is accurate and complete in the system and in accordance with established protocols.
Ensure naming conventions are consistent across all platforms and in accordance with department documentation requirements.
Create appropriate member/provider notification based on request outcome.
Act as a resource to both internal and external customers regarding authorization requests.
Maintain confidentiality and adhere to HIPAA requirements.
Contribute to the Clinical Operations department effort to reach goals.
Participate in cross-departmental workgroups as needed.
Learn how to fix report errors.
Serve as a tester for system updates and/or implementations as needed.
Contribute suggestions to improve processing guides.
Participate in job shadowing as needed.
Cross-train and attend to duties outside of focus area as needed
Process retroactive authorization requests for approvals and determine if claim was denied, and if so, notify claims department to reprocess appropriate claim(s)
Notify providers of admission and discharge dates
Research and resolve questions related to hospitalizations or other facility admissions and discharges
Work with clinical staff to ensure length of stay follows required procedures and meets federal compliance standards
Review census reports daily to ensure timely review is conducted
Experience and/or Education
Required
Minimum 1 year experience providing technical, clerical, or administrative support (includes customer service roles that provide technical, clerical, or administrative support)
Preferred
Experience working with electronic medical records
Experience processing Medicare, Medicaid, or commercial plan authorization requests
Experience working with coding and medical terminology
Knowledge, Skills and Abilities Required
Knowledge
Awareness of the Oregon Health Plan (OHP) and Medicare A & B benefit packages
Basic knowledge of medical terminology, ICD10, and CPT coding helpful
Skills and Abilities
Ability to consistently meet production standards
Ability to consistently meet high quality standards
Ability to and willingness to cross-train as needed
Strong computer application skills in MS Office including Word, and Outlook
Ability to learn business applications
Fast and accurate data entry
Ability to attend to detail and accuracy
Good organizational skills
Growing ability to effectively manage multiple tasks, prioritize and process a high volume of work
Communicate effectively, both verbally and in writing
Good customer service skills
Ability to be flexible and adaptable
Ability to use good judgment, personal initiative, and discretion to perform job responsibilities
Ability to work autonomously with moderate level of supervision
Ability to work effectively with diverse individuals and groups
Ability to learn, focus, understand, and evaluate information and determine appropriate actions
Ability to accept direction and feedback, as well as tolerate and manage stress
Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
Ability to hear and speak clearly for at least 3-6 hours/day
Working Conditions
Work Environment(s): ☒ Indoor/Office ☐ Community ☐ Facilities/Security ☐ Outdoor Exposure
Member/Patient Facing: ☐ No ☒ Telephonic ☐ In Person
Hazards: May include, but not limited to, physical and ergonomic hazards.
Equipment: General office equipment
Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.
Work Location: Work from home
We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.
We are an equal opportunity employer
CareOregon is an equal opportunity employer. The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.
