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Care Review Processor II
Care Review Processor IICareers Integrated Resources Inc • Atlanta, GA, US
Care Review Processor II

Care Review Processor II

Careers Integrated Resources Inc • Atlanta, GA, US
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Job Title : Care Review Processor II

Location : Fully Remote, CA

Duration : 6+ months contract

Pay rate : $25.03 / Hr. on W2

Required : must live in CA

Schedule : Sunday to Saturday varied schedules

Job Description :

  • Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioural health and long-term care, for members with high need potential.
  • HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.
  • As part of this role, the selected candidate will be scheduled to work weekends in alignment with department coverage needs.

Essential Functions :

  • Provide computer entries of authorization request / provider inquiries by phone, mail, or fax. Including : o Verify member eligibility and benefits,
  • Determine provider contracting status and appropriateness,
  • Determine diagnosis and treatment request o Assign billing codes (ICD-9 / ICD-10 and / or CPT / HCPC codes),
  • Determine COB status,
  • Verify inpatient hospital census-admits and discharges,
  • Perform action required per protocol using the appropriate Database.
  • Respond to requests for authorization of services submitted to CAM via phone, fax and mail according to Client operational timeframes.
  • Participates in interdepartmental integration and collaboration to enhance the continuity of care for Client members including Behavioral Health and Long Term Care.
  • Contact physician offices according to Department guidelines to request missing information from authorization requests or for additional information as requested by the Medical Director.
  • Provide excellent customer service for internal and external customers.
  • Meet department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores.
  • Notify Care Access and Monitoring Nurses and case managers of hospital admissions and changes in member status.
  • Meet productivity standards.
  • Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
  • Participate in Care Access and Monitoring meetings as an active member of the team. Meet attendance guidelines per Client policy. Follow Standards of Conduct guidelines as described in Client HR policy. Comply with required workplace safety standards.
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