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Health Insurance Intake Specialist - Utilization Management, Southwestern Health Resources (SWHR)

Company: Southwestern Health Resources CIN
Location: Pittston
Posted on: January 27, 2023

Job Description:

Health Insurance Intake Specialist - Utilization Management Utilization Management is looking for top skilled Health Insurance Intake Specialist. Is that you?Work location: Southwestern Health Resources Headquarters, 1601/1603 Lyndon B. Johnson Freeway, Farmers Branch, TX 75234. Work environment: Utilization Management Department. Please note: The Health Insurance Intake Specialist will be an employee of Southwestern Health Resources (SWHR). SWHR is a clinically integrated network formed by Texas Health Resources (THR) and University of Texas Southwestern Medical Center (UTSW). Work hours: Full Time; 40 hours per week. Tuesday - Friday, 9:00am - 6:00pm. Saturday, 6:00am - 2:30pm. This is a Hybrid position, requiring occasional onsite workdays based on department business needs. In-person attendance required at department meetings, trainings and/or other department authorized activities, at the above-mentioned address or other locations as directed by the department management. Organization Highlights Southwestern Health Resources (SWHR) is a patient-centered, clinically integrated network of 29 hospital locations and more than 6,900 physicians and clinicians caring for more than 730,000 patients across 16 counties in North Texas. Blending the strengths of Texas Health Resources and the University of Texas Southwestern Medical Center, SWHR offers an unmatched ability to connect individuals with a full spectrum of nationally preeminent, clinical care. SWHR is the parent of Care N' Care Insurance Co., a leading regional Medicare Advantage health plan providing care to over 12,000 members. At SWHR, we believe healthcare can be more integrated, accessible and affordable for all. Our purpose: to build a better way to care, together. Our promise: to simplify and empower care, for good. Here's What You Need Education High School Diploma or equivalent required. Associate's Degree preferred. Experience Require 2 years of Medical Referrals and Preauthorization experience in a Healthcare setting. Require 2 years' experience in a high production environment in a Healthcare setting. Skills & Abilities High level experience in data entry with accuracy. Excellent typing skills. Excellent phone etiquette. Ability to provide "customer service focus" Work requires ability to communicate effectively with various levels of internal and external contacts. Work requires ability to work with confidential information on daily basis. Interpersonal and teamwork skills to contribute to objectives of organization. Adaptability/flexibility to react positively to changes in work environment. Initiative to improve productivity and quality of work. Knowledge of specific regulatory, Managed Care requirements. Must be proficient in various word processing, spreadsheet, graphics, and database programs including Microsoft Word, Excel, Access, PowerPoint, Outlook, etc. Working knowledge and ability to apply professional standards of practice in work environment. What You Will Do Position Responsibilities The Health Insurance Intake Specialist will be responsible for processing precertification and referral requests for health care services. The duties of this position will include but are not limited to verifying plan coverage/PCP, securing patient demographics, referring physician, current health status including clinical history/physical information, status of admission or discharge and requested procedures. This position will be responsible for reviewing, triaging, and processing precertification and referrals. The Intake Specialist will be responsible for accuracy and completeness of precertification and referral information within the database in accordance to all compliance and regulatory requirements. This role is responsible for communicating authorization information to appropriate individuals within the specified timeframe, inclusive of internal and external clients. The Intake Specialist will respond to inquiries and provide additional information to physicians as needed. They will make outreach calls to providers, facilities, office staff, and/or Case Managers to obtain any clinical rationale, or status updates for UM/UE requests. The Intake Specialist will review requests for appropriate network utilization and will re-direct cases as needed. The Intake Specialist will be responsible for handling volume of inbound and outbound calling from and to providers and members as needed. This position is responsible for providing excellent customer service in handling these calls. They will effectively communicate results to executive management, internal and external clients, and maintain a positive attitude while working in a dynamic, fast-paced environment. The Intake Specialist will adhere to all regulatory and delegation requirements, including turn-around time. Position Functions Performs high level of data entry. Follows standard operating procedures for updating authorizations, including precertification and IP notifications in Care Managements software. Meets any intake production or QA metrics. Responsible for processing, entering, triaging and routing all precertification and referral requests. Ensures the overall data integrity of documents received and entered into computer system. Responsible for following non-clinical algorithms, network tier structure/exceptions, and precertification and referral requirements by health plan for initial organization determinations and referrals. Responsible for following all compliance and regulatory requirements for turn-around time, notification to provider/member, and accuracy/completeness. Supports UM/UE Clinical staff in obtaining clinical information and status of requests. Supports CM Clinical staff in processing referrals to the care management program. Responsible for supporting any assigned special projects pertaining to UM/UE functions, customer service, and care management. Responsible for outreach to providers to obtain necessary information to process precertification and referral requests. Consistently meets performance standards of production, accuracy, completeness and quality. Handles volume of inbound and outbound phone calls with excellent customer service as needed. Updates Care Management appropriate wrap-up codes, break/lunch codes and any other codes for accurate and complete reporting when handling volume of inbound phone calls. Communicates actively and routinely with management team, and staff in handling client services, issues, escalated referral and preauthorization questions. Manages fax server, online requests and phone inquiries and processes requests from each. Secures patient demographics, verify benefits, and requests and enters clinical history as needed. Uses interpersonal/communication strategies with individuals to achieve: desirable/acceptable outcomes/responses, perceptions of satisfaction or acceptance of those involved. Perform procedures required by the assignment: (a) safely, without causing harm, (b) effectively, achieving the intended outcome/result, (c) efficiently, using the fewest possible resources, (d) legally, within the scope of practice/policy. Establishes and/or revises priorities based on: (a) urgency of the patient or organization's needs, (b) resource availability, (c) predetermined schedules, (d) other departments/personnel expectations. Competes all compliance, regulatory and process training within the specified timeline. Demonstrates a high level of critical thinking and detail orientation. Complies with established procedures and personnel policies. Why Southwestern Health Resources As a Southwestern Health Resources employee, you'll enjoy, comprehensive benefits, including a 401(k) with match; paid time off; competitive health insurance choices; healthcare and dependent care spending account options; wellness programs to keep you and your family healthy; tuition reimbursement; a student loan repayment program; and more. Additional perks of being an SWHR employee: Gain a sense of accomplishment by contributing to a teamwork environment. Positively impact patients' quality of life. Receive excellent mentorship, comprehensive training and dedicated clinical and administrative leadership resources. Enjoy opportunities for growth. Explore Southwestern Health Resources Careers for more information and to search all career opportunities. Our Recruitment team invites you to contact us with any questions at

Keywords: Southwestern Health Resources CIN, Scranton , Health Insurance Intake Specialist - Utilization Management, Southwestern Health Resources (SWHR), Executive , Pittston, Pennsylvania

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