Medical Services Representative
Location: Maryland Heights Missouri
Description: Essence is in need of Medical Services Representative right now, this job will be placed in Missouri. For complete informations about this job opportunity kindly read the description below. Join Our Growing Team !
Essence Healthcare serves the people who consume care, the professionals who provide care and the organizations that manage care. Our unique health insurance busin! ess provides consumers comprehensive and affordable coverage focused on wellness and personal service. By innovating at the leading edge of reimbursement, collaboration and clinical informatics, Essence Healthcare is leading the positive evolution of health care.
Essence Healthcare™ offers people with Medicare comprehensive and affordable health insurance that focuses on wellness, care coordination and personal service. Essence’s Medicare Advantage HMOs bundle hospital, medical and prescription drug coverage together into one plan with one affordable monthly premium, and include additional benefits not covered under the Original Medicare program.
This position supports the Medical Management Department, which acts as a resource to all Essence providers and their patients. The MSR administers daily coverage requests for health care services including ambulance transport, inpatient hospitalization, skilled nursing care, home nursing services, durable med! ical equipment, outpatient procedures and pharmaceuticals. Cov! erage requests are made via phone and fax. The MSR also assists in processing pended claims, supports clinical staff and performs administrative tasks as required by the Centers for Medicare and Medicaid Services (CMS).
Role and Responsibilities:
Receive preauthorization and referral requests via provider calls or faxes
Conduct initial benefit coverage and medical necessity clinical screening using Medicare and plan-defined guidelines in coordination with a pre-certification nurse
Enter referrals and authorizations into Facets and provide confirmation of entry back to requesting provider
Assist in the processing of medical claims that pend for medical management review
Document inpatient notifications from facilities and report them to plan and network provider case managers
Perform data entry to support the processing of Health Risk Appraisals (HRAs)
Support the verification process for the diabetes Special Needs Plan (SNP)
A! dhere to regulatory and departmental timeframes for review of requests received
Maintain HIPAA standards and ensure confidentiality of protected health information
Ensure compliance with all state and federal regulations and guidelines in day-to-day activities
Perform special projects as assigned.
Experience - Qualifications - and Education:
High-school degree (GED or equivalent)
Experience using Microsoft Office
Previous Insurance/Pre-Service exp preferred
Prior managed care experience preferred
Call center experience preferred
Medical Terminology a plus
Additional knowledge, skills, and ability required:
Excellent verbal and written communication skills
Excellent customer service skills
Professional demeanor and the ability to work effectively within a team or independently
Having a positive attitude and using proper phone etiquette
Strong decision making skills
Strong organization! al skills
Ability to multi-task
Desire to work in a diverse and! fast-paced environment
Experience with Facets is a plus
Benefits :
In addition to competitive salaries, challenging work assignments, and developmental opportunities, Essence Healthcare offers employees a comprehensive benefits package to include medical, dental, vision, life insurance, short-term and long-term disability, paid time off (PTO), matching 401K, and tuition assistance.
For more information on Essence Healthcare careers, please check out our web site: www.eghc.com/careers
Essence Healthcare is an EEO/AA employer M/F/V/D.
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This job starts available on: Mon, 04 Nov 2013 18:10:00 GMT