Descripción del puesto

Manages notification, preauthorization and eligibility requests via email from Member, Producers, and Providers for assigned region; handles within given deadline and service objectives.

Assigned to manage at least one large producer.

Reviews medical services against policy to determine coverage and exclusions, reads physician information and decides compensability; may request additional information such as medical records to assist in decision making.

Coordinates the negotiation of rates with physicians or third parties outside the network for cases over usual and customary rates to ensure cost contention.

Create and sends letters of authorization and explanations of benefit depending on outcome of case evaluations to Agents/Clients and Providers.

Create and send denial letters to Providers depending on outcome of case evaluations and coordinate with Medical Team to send denial letters to Agents/Clients.

Coordinate with Patient Concierge Services any request for scheduling appointments or Second Medical Opinions.

Coordinates air transfer logistics and authorizations.

Enters notes for every conversation, email and decision in the system so that it is available company wide.

Performs outbound follow up calls after procedure to determine if further care is needed.

Answer inbound calls from Providers, Agents/Clients, as needed, for the coordination of a medical case.

Requisitos

• 3-5 years experience in Health Insurance Claims Service/Precertification area, preferred.
• Strong English (speech, reading and writing) is required. (Proficiency C1 or C2)

Beneficios

• Medical and hospital insurance.
• Food vouchers - Pluxee.
• Assigned parking.
• Integration activities.