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Description
- Evaluation, interpretation, and processing of clinical review requests to include but not limited to applying the following requirements:
- Validation that requests has met submission requirements based on accreditation / governmental regulation requirements.
- Educate and/or communicate with provider offices on appropriate procedures.
- Application of internal policies and procedures, contractual provisions, and regulatory requirements.
- Multi-system validation of member specific eligibility, benefit and provider requirement for selected service(s) based on member's primary line of business.
- Utilization of various resources to confirm HMSA's clinical review requirements; as required, educate and/or respond to provider office with outcome.
- Creation of the electronic file within the Utilization Management (UM) management system for review.
- Adhering to the guidelines and processes for management of documents within the Fax Manager Application (FMA).
- Process vendor authorization files to reflect the appropriate decisions within HMSA's system to appropriately and accurately impact claims processing to include but not limited to the following:
- Researching, validate and update existing authorizations based on extensions, peer to peer reviews and updates requested from provider community.
- Monitoring and addressing errors as a result of the request program load feature.
- Notify and/or communicate issues associated with authorization files with unit coordinator, supervisor or UM Solutions Administrator.
- Resolve, document and accurately respond to inquiries, issues or complaints received telephonically from provider (and members) by:
- Application of Ulysses Call Strategy servicing skills.
- Researching multiple system and/or online document resources
- Contacting unit leads or resources for additional explanation.
- Triage and transfer calls to appropriate areas upon request or require a subject matter expert (SME).
- Escalate calls as appropriate taking into account urgency, customer's level of concern, knowledge required to respond in an accurate manner.
- Processing of the Aerial to QNXT (A2Q) error / balance reports by:
- Accurately building UMD documents within QNXT to support the claims processing activities.
- Notify and/or communicate issues associated with A2Q process to unit coordinator, supervisor or UM Solutions Administrator.
- Monitor and processing of clinical review requests received via online authorization tool by:
- Applying internal policies and procedures, contractual provisions and regulatory requirements.
- Multi-system validation of member specific eligibility, benefit and provider requirement for selected service(s) based on member's primary line of business.
- Triaging and distribution of the cases to the respective units taking into account type of service, place of treatment, provider relationship and line of business.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
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