Health Services Representative

JOB SUMMARY:

 

The Health Services Representative position plays in important role in the success of Arcadian Health Plan and as such is responsible for assisting in the implementation and ongoing management of AHP?s Health Services programs, consisting of Utilization Management, Quality Improvement, and Appeals/Grievances.  This position is multifaceted and requires a diverse set of organizational skills.  The Health Services Representative is positioned strategically to work closely with physician office staff, physician reviewers, the Medical Director, research nursing staff, member services staff, provider relations staff, service center staff and Health Plan members. 

 

QUALIFICATIONS:

 

? Education: 

? Associate degree or equivalent from an accredited college

 

? Experience:

? Minimum of 2 - 5 years office experience in a medically related field (e.g., physician office, home health department, HMO, IPA)

? Proficient with computer and software programs (e.g.; Microsoft word, excel) and the Internet

? Experienced in data entry, 10 key data entry

? Type 50+ WPM

 

? Skills:

? Excellent administrative, organizational, and follow-up skills

? Proficient in medical terminology

? Familiarity with ICD9-CM, RBRVS, CPT and DRG coding

? Familiarity with claims processing

? Effective communication style (written and verbal) with proven ability to positively influence behavior and arrive at a ?win-win? resolution

? Excellent telephone skills

? Excellent written communication skills

? Demonstrated skills in problem resolution

? Independent thinker, logical and problem solve

? Ability to implement policies and procedures

 

 

? Job Duties and Responsibilities:

? Assist the licensed medical staff with the non-clinical tasks associated the performance of pre-authorization, concurrent, and retrospective review for all inpatient and outpatient services, as outlined in the utilization management program; for example:

? Intake authorization and referral requests

? Assign procedure or diagnostic codes as necessary

? Enter requests into computer

? Upload clinical notes to appropriate authorization files

? Ensure that fax notifications are sent within turn-around-timeframes

? Follow up with Medical Director on outstanding requests

? Communicate with providers on status of outstanding requests

? Verify member eligibility via computer; submit eligibility requests to Eligibility Department and follow up until determination is made

? Determine member benefit coverage and refer to Medical Director when appropriate

? Perform duties in such a way as to insure that health plan meets CMS guidelines and delegation requirements for utilization management, appeals & grievances, and quality improvement.

? Provide administrative support to the medical director in the development, implementation and ongoing management of the following:

? Denial and appeal process/letters

? Preferred provider list

? Filing

? Perform administrative duties as necessary, included but not limited to, answering the telephone, filing, typing, assembling, and distributing manuals, letters, lists, minutes, etc?

? Coordinate and assist in preparation for UMC and QIC Meetings (e.g. create agenda, minutes, prepare packets, signed attendance records, signed confidentiality statements)

? Prepare for CMS audits; including preparation of member files, meeting minute binders, policy and procedure binders

? Responsible for processing appeal & grievance files to completion to ensure CMS compliance regulations are met, including but not limited to:

? Monitoring and working MAGS (Member Appeal & Grievance System)

? Compiling and sending appeal & grievance letters

? Requesting medical records

? Compiling and sending MAGS files to CHDR

? Preparation for CMS audits

 

 

Physical Requirements of the Position:

? Sitting:  The essential functions of this job are performed while seated at a desk or work station for at least 75% of scheduled work hours

? Standing and walking: The essential functions of this job require the ability to move from one location to another either by walking or driving.

? Hearing:  Must be able to receive and send detailed information through oral communication and clearly understand people speaking in her/his presence and over the telephone

? Speaking:  The essential functions of this position require speaking and communicating English in a clearly understood voice at all rimes during scheduled work hours

? Fingering and repetitive motions:  Functions of this position require a significant amount of movements of the wrists, hand, fingers in the use of office equipment such as phones and computer keyboards

? Vision:  The essential functions of this position require the ability to clearly see detailed information via written manuscript and or computer

? Lifting:  A function of this position requires the ability to lift at least twenty-five pounds on an occasional basis.

 

Salary:  Starting salary is based on qualifications and experience. In addition, Arcadian does not permit or provide compensation or anything of value to its employees or agents, condition employment of its employee or agent evaluations, and set its employee or agent performance standards, based on the volume of adverse determinations, reductions or limitations on lengths of stay, benefits, or services.