Position Summary:
The Health Professional 3 conducts utilization review, and/or telephonic customer care; problem resolution, follow up and further related services for patients and members. This key individual focuses on member engagement, education, and empowerment, establishing recommendations that manage chronic health conditions and are conductive to healthier lifestyles. Must be available while non-clinical staff performs initial screening.
Essential Functions:
Provides telephonic and/or in person health coaching and consultation for participants and members, while meeting company policies and procedures. Verifies and documents member eligibility for services. Investigates, reviews, and maintains data related to treatment, care and/or related services and identifies barriers that could affect or interfere with treatment effectiveness or adherence. Performs triage and urgent clinical risk assessment, clinical expert consultation, short-term problem resolution, clinical emergency or urgent services coordination, referral and/or follow up for members seeking services, as needed. Participates in organization determinations for either Inpatient or Partial Hospitalization cases including pre-certification and concurrent reviews, while discussing clinical/medical necessity concerns within house Physician Advisor, as needed. Collaborates with other professionals to obtain better treatment results and overall care. Communicates and interacts via “live” encounters with providers to facilitate and coordinate the activities of the Utilization Management process. Verifies and adjusts Census reports for all Inpatient/Partial Hospitalization facilities, conducts concurrent and retrospective reviews while meeting company policies and procedures. Collaborates with facilities in the Discharge planning. Completes Discharge summary using the clinical information provided by facilities at case closure. Generates authorization numbers for payment purposes, for all Inpatient or Partial services as determined in the review process. Applies APS authorization process (Milliman standards, policies, procedures, and contractual agreements) to submitted information. Authorizes services in accordance with medical and health guidelines. Coordinates with the referral source if there is not sufficient information available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows process for requesting additional information. Provides timely verbal/email/fax organization determinations to the requesting provider and/or members as per policy. Submits appropriate documentation/clinical information to clerical support for record keeping, mailing notifications and documentation requirements. Recognizes opportunities for referrals to Behavioral Health Case Management and refers accordingly. Identifies quality concerns through the review process and refers them to Quality Department for further investigation.Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS), NCQA, URAC and guidelines set forth by other regulatory agencies & HIPAA where applicable; obtains necessary professional and continuing education required for licensure and any applicable certifications. In addition, all other duties assigned by the manager and/or supervisor.Education:
Master’s Degree in a Behavioral Health field or bachelor’s degree in Nursing. Current, unrestricted clinical license(s) to practice in Puerto Rico territory.Experience:
Minimum 2 years of experience in a Clinical, Behavioral or Managed Care field preferred.Knowledge:
Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.Strong knowledge in behavior principles, chronic illnesses, and disease management. Strong telephonic assessment and customer service skills.Knowledge in community-based resources.Knowledge in clinical assessment and crisis intervention.Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum. Read LessPosition Summary:
The Health Professional 1-Pharmacy Call Center Representative manages telephone calls from pharmacies and providers related to pharmacy benefits, authorization requests, drug use review, among others, to ensure that claims are correctly and timely adjudicated.
Essential Functions:
1. Answers and manages telephone calls from pharmacies and providers in a timely, confidential and courteous manner.
2. Documents calls and/or drug requests with complete follow-up history of the patient through electronic records.
3. Provides orientation to pharmacies regarding pharmacy benefits.
4. Performs system overrides (e.g., prior authorization) on the PBM claims processing system to ensure that claims are
correctly adjudicated.
5. Assists pharmacies claim processing.
6. Assist in the training of pharmacy representatives.
7. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable.
8. In addition, all other duties assigned by the manager and/or supervisor.
Education:
Pharmacy Technician Course of accredited school.Possess an active professional unrestricted Pharmacy Technician License in good standing to practice in Puerto RicoExperience:
· Minimum 2 years’ experience in retail pharmacy preferred.
Knowledge:
· Basic knowledge of physical and mental pharmacotherapies, in order to make accurate assessments of clinical cases.
· Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
Read LessResumen del Puesto:
El Asistente Administrativo recibe y dirige las llamadas entrantes, recibe a los visitantes, mantiene el registro de visitantes y las credenciales, y proporciona información y asistencia general al público. Esta persona clave recibe el correo entrante y ayuda en la preparación y distribución de materiales de la empresa. El Asistente Administrativo realiza funciones rutinarias de apoyo en la oficina, incluidas la elaboración de documentos y el archivo. Este empleado no es responsable de realizar actividades de revisión de UM que requieran interpelación de información clínica.
Fuciones Esenciales:
Realiza actividades administrativas y de apoyo de oficina para múltiples supervisores, como ingreso de datos, procesamiento de textos, creación de hojas de cálculo, informes y presentaciones, y/o archivo.Recibe y flitra todas las llamadas entrantes y dirige las llamadas entrantes y dirige las llamadas entrantes y dirige las llamadas al personal correspondiente.Recibe a los clientes internos y externos de manera oportuna, manteniendo el registro de visitantes y la preparación de credenciales.Proporciona información general y orientación a visitantes y en las llamadas.Recie el correo entrante y distribuye los documentos de manera adecuada.Coordina el correo y paquetes salientes, asegurando una entrega eficiente y oportuna.Proporciona apoyo administrative como procesamiento de textos, envío de faxes, fotocopiadora, entrada de datos y envíos de correspondencia, al personal de la organización. Solicita suministros de oficina y coordinar servicios de equipos comerciales con otros proveedores relacionados con las instalaciones según sea necesario. El uso de datos clínicos se limita a: la revisión de solicitudes de servicios para verificar la integridad de la información; recopilación y transferencia de datos no clínicos; adquisición de datos clínicos estructurados; y actividades que no requieran evaluación o interpretación de información clínica.Cumple con todas las directrices establecidas por los Centros de Medicare y Medicaid (CMS) y con las directrices reguladoras cuando corresponda. Además, todas las demás tareas asignadas por el gerente y/o supervisor.Educación:
Grado Asociado en Ciencias Secretariales o equivalenteEscuela SuperiorExperiencia:
Mínimo 2 años de experiencia en el puesto de asistente administrativo o similar; experiencia en atención al cliente en centro de llamadas.Conocimientos:
Conocimiento en facturación médica, preferiblemente en un entorno de atención médica. Experiencia con computadoras y conocimiento de programas de Microsoft Word, Excel, Power Point y Outlook al menos un nivel intermedio. Read LessPosition Summary:
The Administrative Assistant receives and routes incoming calls, greets visitors, maintains visitor log & badges and provides general information and assistance to the public. This key individual receives incoming mail and assists in preparation and distribution of company materials. The Administrative Assistant performs routine office support functions, including word processing and filing. This employee is not responsible for conducting any UM review activities that require interpretation of clinical information.
Essential Functions:
Performs administrative and office support activities for multiple supervisors, such data entry, word processing, creating spreadsheets, reports and presentations, and/or filing. Receives and screens all incoming calls and channels calls to the appropriate personnel. Greets internal and external clients promptly, while maintaining visitor log and badge preparation. Provides general information and guidance to callers and visitors. Receives incoming mail and distributes documents appropriately. Coordinates outbound mail and packages while ensuring efficient and timely delivery. Provides clerical support such as word processing, faxing, copying, data entry and mailings, to organizational staff. Orders office supplies and arranges business equipment services with other facility-related vendors as needed. Use of clinical data is limited to: Performance of review of service request for completeness of information; Collection and transfer of non-clinical data; and Acquisition of structured clinical data; and Activities that do not require evaluation or interpretation of clinical information.Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable. In addition, all other duties assigned by the manager and/or supervisor.Education:
· Associate degree in Secretarial Science or equivalent experience preferred
· High School degree
Experience:
· Minimum 2 years of experience in administrative assistant position or similar; call center customer service experience.
Knowledge:
· Knowledge in medical billing, preferably in healthcare setting.
· Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
Read Less