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The Call Center Care Manager is responsible for ensuring that members receive their optimal level of benefit coverage for services that require prior authorization. Observes for the quality and correct utilization of the services. Serves as primary liaison between companies’ enrolled beneficiaries and providers, for the purpose of Member/Providers process of request of services requiring pre-authorization in a Call center environment.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Receives requests for prior authorization for services by phone call,fax or electronically. Reviews and evaluates the request for completeness. Assures coverage of Pre-authorization call center during operation hours or as requested. Answers all department incoming calls in a polite and professional manner and follow HIPAA regulations. Follow the call center policies and procedures. Have to meet with the established amount of cases and with the quality measures. Document each transaction in the system. Handle members, peers and providers incoming telephone calls and dispose of properly via appropriate transfer, or completing the request of services. Also, manage and complete the requests received by fax, call or ellectronically. Performs outbound calls to members or providers as needed and to assure compliance with regulations.. During operations hours assures coverage of Customer Service call center. Reviews the request to determine:
Benefit level verification;
Coordination of Benefits;
Identification of benefit limitations/exclusions;
Review of medical information utilizing standard criteria, protocols or guidelines as defined by the health plan;
Appropriate requesting and service provider.
Approves requests that meet the eligibility, benefit coverage, and medical necessity criteria. Approves and/or facilitates access. Coordinates care across settings and providers. Requests additional clinical information to network providers as needed . Offer support to Call Center Representatives to do the determination of cases. Forwards all requests that do not meet medical necessity criteria to the Psychiatric Consultant or Medical Director for determination. Seeks out appropriate resources and assists in the resolution of member's issues refered from other departments . Performs additional job related duties as assigned Answers all department incoming calls in a polite and professional manner. Works on a variety of special projects and assumes other duties as assigned by the Pre Authorization Supervisor or Manager .
20. It is responsible to meet with the HIPAA regulation and the department policies and procedures.
21.Participates in workshops and trainings. Assists in the training of other employees as needed.
22. Promote quality customer and provider service through team efforts.
23. Exhibits flexibility, sensitivity and respect, maintaining a working relationship with all company staff.
24. Participates on staff and/or multidisciplinary meetings as requested.
25. Participates on applications upgrades, testing and/or new tools implementations
EDUCATION AND EXPERIENCE
Bachelor Degree in Science of Nursing with Current Puerto Rico RN license and member of College of Nursing Professionals of PR and/or Masters Degree in Social Work, Psychology and/or Phychological Counselling and current valid lincense and collegiate as applicable. Two to five years of experience or more in acute care setting. One to three years experience in a managed care setting preferred. Health Care Call Center experience preferred.
GENERAL SKILLS AND REQUIREMENTS
Working knowledge of clinical criteria application in the decision making process preferred. Familiarity with Medicare clinical criteria preferred. Ability to work under pressure, independently and make appropriate decisions within the realm of nursing practice and judgment. Computer literate in Microsoft Windows applications, software and Internet. Must be able to sit for long periods of time with sufficient mobility to perform all job duties in the office environment. Performs tasks requiring independent knowledge and judgment in addition to instructions and procedures provided. Must be able to function with frequent interruptions, accept change, and be able to prioritize tasks efficiently when faced with competing demands. Must have the ability to work as a team player with excellent bilingual, verbal and written skills.
Ability to speak, read and write in English and Spanish, preferable Bilingual in English to Spanish. Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence , and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, members, Medical Providers and the public.
Ability to work with basic mathematical concepts. Ability to calculate figures and amounts such as proportions, percentages, volume. Ability to apply concepts of basic algebra and geometry. percent and to draw and interpret bar graphs.
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
PHYSICAL AND MENTAL DEMANDS
Requires sitting and standing associated with a normal office environment. Regularly talks and hears. This position requires that weight be lifted or force be exerted up to 10 pounds.
ENVIRONMENTAL AND WORKING CONDITIONS
Normal office environment. The noise is typically moderate. Evening or weekend work, as necessary.
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