BPO Medical Review Specialist
Allied Benefit Systems, LLC, United States
Job Description
Job Title: BPOMedical Review Specialist
Department: Claim OperationsFLSA Status: ExemptJob Status: FT
Reports To: Supervisor, Claim Operations Job Class: 5
Positions Supervised: N/A
Work Schedule: Flexible full-time hours
Assessments: Predictive Index Behavioral and Cognitive assessments
Position Summary
The BPO Medical Review specialist will be responsible for reviewing and analyzing referrals and all supporting documentation to determine medical necessity. The BPO Medical Review Specialist will review medical appeals, medical review referrals, and medical necessity referrals prior to sending to our outside vendors for review. The medical review specialist will also be responsible for composing response letters, if needed and review urgent referrals to determine Medical Necessity.
Responsibilities
- Review Summary Plan Documents to determine coverage/exclusions prior to prepping referral
- Document the QicLink system and database to show referrals received and sent to vendors as well as determinations made within the unit
- Respond to all inquiries sent to the department by other departments and from vendors
- Compose response letters to providers and members
- Communicate with examiners, other departments, and the clients when necessary
- Review urgent referrals and Plan renewals to determine Medical Necessity
- Prioritize incoming referrals to complete all tasks timely
- Support with inventory numbers and performs follow up on outside reviews to insure prompt turn-around on referrals
- Support the logging, faxing, and posting of referrals
- Support faxing response letters to providers/members
- Other duties as assigned
Position Qualifications
Communication Communicates effectively both internally and externally, where applicable. Includes both written and verbal communication.
Customer Focused Works well with customers/clients both internal and external, promotes a positive image of the company and department, and strives to solve issues raised by customers.
Dependability Meets deadlines, works independently, accountable, maintains focus, punctual, and maintains good attendance record.
Initiative Takes action independently, seeks new opportunities, and strives to see projects to completion.
Interpersonal Skills Builds strong relationships, is flexible/adaptable, works well with others, and solicits feedback.
Job Knowledge Understands the facets of job, aware of duties and responsibilities, and keeps job knowledge current.
Organization Skills Information organized and accessible maintains efficient work space and manages time well.
Problem Solving Strives to understand contributing factors, works to resolve complex situations.
Productivity Manages workload, works efficiently, and meets goals and objectives.
Self-Development Looks for opportunities to increase knowledge, works to increase responsibility, strives to achieve personal goals and/or maintains licenses and other pertinent requirements.
Sense of Urgency Meets deadlines, establishes appropriate priority, and completes tasks assigned in timely manner.
Teamwork Accountable to team, works to meet established deliverables, appreciates view of team members, and respectful.
Technical Skills Maintains current understanding of technical process/equipment, uses technology to increase performance/productivity; effectively uses online tools and resources.
Skills amp; Abilities
Applicant must be proficient at the use of Microsoft Word, Excel, Access and Outlook programs, and able to easily learn other data systems.
Experience
Applicants must have comprehensive experience with medical terminology and administrative experience. The applicant must have the ability to analyze claim situations, take appropriate actions and be great with communication and documentation. Medical ICD 10 and Coding experience and knowledge required.
Education
High School Education required.
PHYSICAL DEMANDS
Sitting, working at a computer for long periods of time.
WORK ENVIRONMENT - Flexible hours, ability to work from home upon tenure requirements and approval from manager.