The position is responsible for the claim management of medical only files and ensuring utilization review compliance.
Essential functions' means the fundamental job duties of the employment position the individual with a disability holds or desires. 'Essential functions' does not include the marginal functions of the position." "A job function may be considered essential for any of several reasons, including, but not limited to, any one or more of the following: (A) The function may be essential because the reason the position exists is to perform that function. (B) The function may be essential because of the limited number of employees available among whom the performance of that job function can be distributed. (C) The function may be highly specialized, so that the incumbent in the position is hired for his or her expertise or ability to perform the particular function. The Americans with Disability Act (ADA) denotes "Essential functions" as essential functions of this position include, but are not necessarily limited to, those specifically identified in this description. The position and its essential functions may change over time and these changes may not necessarily be reflected in the position description. The Company may, at its sole discretion, add to, change, or expand the essential or marginal functions of the position.
Demonstrate proficiency in claim handling practices, to include investigation, case management, case evaluation and documentation.
Successfully pass all regulatory, internal and external audits
Recognize and address coverage issues, potential fraud and subrogation.
Ensure effective and timely responses to our internal and external customers, timely and professionally.
Follow special handling instructions regarding client-specific processes and procedures.
Establish, document and execute strategies that lead to timely and favorable claim disposition.
Keep Medical Only files on current diary system to timely monitor new developments and to follow up on outstanding requests. Respond to all other diary activities.
Successfully complete the annual corporate Code of Conduct Training.
Ensure compliance with company established medical treatment authorization procedures as well as all statutory regulations and timeframes
Assist in ensuring the timely approval of medical care and vendor referrals
To progrom this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required:
Ability to work independently within company procedures and statutory guidelines.
Strong written and verbal communication skills.
Exceptional customer service skills.
Ability to anticipate problems and resolve issues proactively.
Computer skills and knowledge of relevant software.