Care Management Coordinator, Pittsburgh PA

Pittsburgh, PA
Full Time

Job Description

Care Management Coordinator performs accurate and timely processing of pre-certification requests for authorization of medically necessary health care services, at the appropriate level of care, based on the benefits for the line of business, and in compliance with organization policies, procedures and regulatory requirements.

• Proactively inform designated individuals of the status of work assignment to assure decision timeframes and notification requirements are met.
• Communicate effectively with Utilization Management Staff, providers, other internal and external customers and management.
• Route Cases Based on Established Guidelines.
• Provide accurate and timely routing of service requests to the nurse reviewer to assure that the decision and notification timeframes are in compliance with regulatory guidelines.
• Process service requests meeting established guidelines, and document and route requests that are not permitted.
• Request additional information verbally and in writing when the information provided is not adequate to make a medical necessity determination.
• Maintain or exceed department call center standards.
• Adhere to line of business phone standards to assure regulatory requirements are met.
• Utilize phone functions to monitor the number of calls in queue and wait time.
• Utilize daily phone standard reports to assess opportunities for self-improvement.
• Meet or exceed standards for other production and quality measures.
• Other duties as assigned or requested.

• Experience in customer service
• Experience in typing, keyboard and computer skills
• Work experience in medical terminology
• Associates degree or certification in a health related occupation, preferred
• Work experience with ICD-9 and/or CPT coding, preferred

Additional Details

Experience: 0-2 years