Job: Care Management Coordinator (Temporary role)

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Posted: 12/06/2017

Job Status: Full Time

Job Reference #: 2017-R0140935

Job Description

Care Management Coordinator (Temporary role)


Daily Schedule-Days
Scheduled Hours per 2-week Pay Period-80
Weekends Required -None


Theprimary role of the Care Management Coordinator is to coordinate the referraland prior authorization processes in accordance with the benefit contractguidelines and criteria.  Using good oraland written communication skills, implements, maintains and executes proceduresand processes by which QualChoice Health Plan Services (QCHPS) - MedicareAdvantage health plans performs its referrals and prior authorizations.

Essential Duties and Responsibilities

·       Processphone and fax authorization requests for medical services from physicians andhospitals (providers) in an efficient, accurate, and customer focused manner inaccordance with established criteria sets and established QCHPS - MedicareAdvantage health benefits and requirements.

·        Verify eligibility and benefits for servicesrequested by Primary Care and Specialty Physicians from Health Plan guidelinesand maintains documentation in system

·       Proficientlyassist with all telephone inquiries from providers and members regardingproblems, benefits inquiries, referral and authorization status or copies ofletters and data

·       Determinewhen to refer to Care Management Director for higher level of review whenindicated by request

·       Maintaintracking and monitoring of assigned referrals at all levels of review forinstant retrieval

·       Performdaily computer entry of referral information following established protocolsand guidelines for monitoring quality and timeliness of entry with minimalerrors

·       Providesaccurate and timely daily Activity Reports as required in Department Policiesfor production information

·       Meetproduction standards for performance as set by supervisor for the department

·       Coordinatereceiving, processing, and resolving provider reconsiderations in accordancewith all applicable contract provisions, plan policies, procedures, rules andregulations and coordinate with Claims and other departments to ensure timelyresolution

·       Respondto daily questions from delegates, medical offices, hospitals, skilled nursingfacilities, and home health agencies about the necessary steps of the medicalreferral and authorization process, benefit interpretations, and claimsprocessing

·       Initiatescommunication with delegated groups, physicians, their office staff, and outsideproviders as needed to gather information for processing referrals andauthorizing services to Managed Care patients

·       SupportConcurrent Review and Case Management as needed

·       Assistin the development and implementation of job specific policy and procedurespertaining to but not limited to accurate data entry, rapid telephone response,provider reconsiderations, and following guidelines for authorizations

·       Reviewcurrent and proposed Federal, State, CMS, and NCQA standards that regulateUtilization Management activity

·       Assistwith and conduct review of retrospective referrals and/or claims to verify allauthorized services were performed as specified

·       Assistin preparing and submitting projects, reports, or assignments as needed to meetdepartment initiatives and/or objectives

·       Otherduties as assigned

Education and Experience

·       HighSchool education required

·       1-2years demonstrated working knowledge of Managed Care products preferred

·       Medicareexperience preferred

·       Abilityto type 40 wpm

·       Experiencewith Microsoft Office Suite

·       Experiencein lieu of above qualifications will be considered


Knowledge, Skills and Abilities

·       Knowledgeof Utilization management policies and procedures

·       Knowledgeof health plan products and services and related regulations that can be usedto provide exemplary service

·       Strongleadership skills

·       Excellentpublic relations and communication skills

·       Excellentconceptual, organizational, and problem solving skills

·       Wellorganized with the ability to maintain attention to detail

·       Abilityto work well in stressful situations


We’re an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.  

Requisition Title

QualChoice Health

Application Instructions

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