DME Coordinator - Jefferson Health Plan

Job Details

Works under general supervision, collect and process information related to inpatient and outpatient authorization requests for services via Medical Management system, provider portal and call center function. The coordinator also facilitates authorizations through the technical authorization and payment cycles.

Job Description

• Follow all company and department policy and procedures.
• Process and create authorizations requests for emergency admissions, elective inpatient admissions, outpatient services in a medical and home setting, DME emergent and urgent maternity and newborn delivery admissions as per departmental guidelines.
• Identify duplication of services and communicate to appropriates team members.
• Follow up to confirm outstanding prior authorizations to confirm status and update system and authorization.
• Manage authorizations coming through the provider portal via the 278 transactions into Medical management system and perform quality assurance of all required fields prior to reassignment to appropriate case manager.
• Responsible to process all cases assigned by leadership.
• Monitors and prepares clinical information and record maintenance for submission to QIO (Quality Improvement Organization).
• Create cases for non -par providers with a temporary provider ID and collect pertinent provider information and refer via Medical Management System to Network Management team for completion of MHS set up for claims payment.
• Monitor provider portal for failed and duplicate authorizations for provider re-education.
• Provide continuous call center telephone service in a prompt and courteous manner. Maintaining call service thresholds.
• Verify member’s eligibility via internal eligibility system and/ or DHS terminal and alert case managers of change in eligibility status.
• Code all services accurately using appropriate ICD-10 codes CPT and HCPCS coding systems.
• Reconcile claim discrepancies via Service forms sent and meet the Service Level Agreement of (3) three business days turnaround time.
• Identify resolution of outstanding claims issues generated by a provider inquiry and or written request.
• Assist member services and provider services in addressing member or provider questions regarding service authorization questions and, general customer service for both internal and external customers.
• Support Clinical Case Managers by closing cases when applicable.
• Maintain Key Indicator thresholds for established phone service for the department
• Triage of Medical Management clinical faxes for timely medical necessity review.
• Attach faxes to the member’s case in (Medical Management System).
• Work with Applications Systems Management (ASM) team to identify system failures that directly impact claim payment and data integrity

Education and Experience:

• High School Diploma/GED
• 2 years in health care experience
• Proficient use of Microsoft Office suite (Word, PowerPoint, Excel) required.
• Knowledge of medical terminology, utilization review systems, hospital admission systems, health care claims or medical office administration.
• Demonstrate ability to work and communicate effectively with co-workers, members and providers at the owner institutions.
• Ability to work independently and as a team player.
• Ability to work on detailed reports.
• Demonstrate excellent organizational skills and ability to competently handle multiple responsibilities at one time
• Demonstrate excellent telephone and verbal/written communication skills.
• Other duties as assigned

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Health Partners Plans, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research.