The Medical Management Coordinator (MMC) supports the Medical Case Manager with the intake, completion and copy work of all outgoing letters and documents that pertain to prospective, concurrent or retrospectively certifications, delays, denials, and modification decisions in an effort to meet mandated deadlines. This is a high volume desk.
Essential Duties and Responsibilities include but are not necessarily limited to the following. Other duties may be assigned.
- Maintain strict HIPAA Confidentiality; follow all internal policies and procedures to maintain the confidentiality for all members and member data.
- Follow written criteria, policies and procedures in reviewing and processing daily referrals for outpatient and in patient medical care.
- Adhere to exact deadlines; determination letters must be sent out to the appropriate parties within 24 hours of the medical determination.
- Responsible for considering eligibility, benefits, medical necessity, and appropriate providers to decide the disposition of a referral.
- Remain in constant daily contact with other Medical Management staff, Medical Case Management Supervisor, BRMS staff/departments, Physician Reviewers and other providers; the health plans and applicable staff; and in network and out of network office staff.
- Authorize medical services by using medical policy guidelines of the department to process sensitive and confidential information; refer the request to an RN Medical Case Manager or a Physician Reviewer as appropriate.
- Work independently on assigned tasks and activities, based on established policies and procedures.
- Enter all UR data in the Medical Utilization Review system with accuracy and completeness (99% of the time).
- Review all medical reports to identify treatment requests within 24 hours of receipt
- Review medical reports thoroughly to ensure treatment is consistent with the diagnosis provided
- Review and analyze the Medical Utilization Review screen to ensure treatment certifications remain within established authority levels and to avoid duplication of treatment.
- Perform other duties and responsibilities as assigned by the Management.
Knowledge, Skills, & Abilities:
- Strong communication skills, effective and accurate written and verbal form.
- Patient care evaluation skills.
- Strong customer service oriented skills for both internal staff and external clients.
- Strong organizational skills which support timely and well documented action to manage concurrent deadlines and multiple priorities.
- Keyboarding skills and the ability to utilize computer equipment and software are required as is experience with other types of standard office equipment. Minimum 45wpm and 10 key by touch required.
- Strong working knowledge of Microsoft Office, excel, windows based products and software specific to document scanning.
- Medical terminology preferred.
- Working knowledge of ICD-9, HCPCS and CPT coding.
- Ability to work independently and within a team environment.
- Knowledge and ability to utilize evidence based medical guidelines.
- Durable Medical Equipment knowledge preferred.
- Must be able to, with reasonable accommodation, sit for extended periods of time; view and input data on PC for extended periods of time; stand, stoop, lift, carry and walk on an intermittent basis.
- Must be able to work within core hours of operation 0700 to 1700 Monday through Friday.
This job has no supervisory responsibilities.
Education and/or Experience:
High School diploma or G.E.D, college degree preferred; and minimum of two to four years medical or insurance experience; or equivalent and any combination of education, training, and/or experience, which demonstrates ability to perform the duties described.