Utilization Review Intake Coordinator Bilingual Spanish

Job description

Johnson Service Group (JSG) is seeking a Bilingual Utilization Review Coordinator.

This position is remote - MUST WORK Pacific Standard Time (PST) hours

Work Schedule- Monday -Friday / 8:00am PST- 5:00 pm PST

Pay rate- $20.00- $23.00 per hour



JOB DESCRIPTION SUMMARY

Reports to the Nurse Supervisor and assists in the process of health management and utilization review (UR).

The incumbent will accomplish this by entering pre-service, concurrent, and post-service requests received from health care providers for medical services, and completing selected authorizations as directed by the UR Nurses.

Reach out to both potential and existing Health Management (HM) members to arrange appointments with the HM coaching team.

Keep track of incoming service inquiries and deliver outstanding customer service to both our internal and external clients.



QUALIFICATIONS

• High school education or equivalent and/or two years’ experience in health insurance environment.

• Experience in Utilization or Case Management Department interacting with clinical staff.

• Good understanding of health benefits claims processing, knowledge and understanding of current procedural terminology (CPT), healthcare common procedure coding system (HCPCS) and international classification of diseases (ICD) 9/10 codes preferred.

• Good understanding of generally accepted medical practices and knowledge of state and Employee Retirement Income Security Act (ERISA) mandated benefits, plan language and contracts preferred.

• Good knowledge of medical terminology, hospital, clinic or laboratory procedures preferred.

• Proficient in Microsoft Office (Word, Excel, Outlook) and electronic health record software.

• Detail oriented with strong analytical skills.

• Motivated self-starter with the ability to work independently, as well as, part of a team.

• Excellent verbal and written communication skills.

• Proficiency in both English and Spanish is required.

• Comprehensive command of the Spanish language with the ability to utilize it up to 50% of the time.

• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.

• Home router with wired Ethernet (wireless connections and hotspots are not permitted).

• A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)



DUTIES AND RESPONSIBILITIES

Administrative Support

• Review all utilization requests and forward, research, and analyze to determine if clinical or administrative in nature.

Forward clinical issues to the appropriate staff for processing and handle administrative issues as appropriate.

• Enter accurate and complete authorization information into the system.

Generate member and provider approval letters, as appropriate.

• Clarify CPT, HCPCS, and ICD-10 codes with conflicting, missing, or unclear information by consulting with provider’s staff.

Maintain positive relationships with provider offices.

• Determine the eligibility of the member and resolve questionable eligibility with Administration department, as appropriate.

• Transmit correspondence or medical records by mail, e-mail, or fax.

• Assess network status of requested providers.

If non-network, determine if alternate network providers are available to provide same service.

Communicate non-network status to requesting provider and ensure member is aware of same.

• Protect the security of medical records to ensure that confidentiality is maintained.



Operational Support

• Work with Claims, Customer Service, Provider Maintenance and Contracting staff to provide complete information necessary for clinical review.

• Complete letter of agreement (LOA) requests for medically necessary services as needed.

Follow up with Contracting Department for results on negotiations.

• Ensure providers and members are notified and document when out of network services have been requested.

• Operate the telephone queue according to department benchmarks and break schedules.

• Maintain professional telephone etiquette demonstrating patience and willingness to assist callers.

• Maintain records of all patient related phone conversations in the authorization system.

• Scan, enter, and approve retrospective authorization requests and claims as directed by clinical staff.

• Ensure retrospective claims are not duplicates by researching in claims system.

• Utilize clinical staff for concerns and questions regarding processing of retrospective requests.

• Adhere to desktop procedure for managing retrospective requests and get authorization for J-codes prior to processing.

• Schedule meetings for participants with the HM team.



Other

• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.

• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.



JSG offers medical, dental, vision, life insurance options, short-term disability, 401(k), weekly pay, and more.

Johnson Service Group (JSG) is an Equal Opportunity Employer.

JSG provides equal employment opportunities to all applicants and employees without regard to race, color, religion, sex, age, sexual orientation, gender identity, national origin, disability, marital status, protected veteran status, or any other characteristic protected by law.  

Required Skill Profession

Information And Record Clerks