Intake Specialist-Utilization Review - Care N Care Insurance Company of North Carolina

JOB SUMMARY

The Intake Specialist will be responsible for entering requested authorization of health care services received via telephone, internet, and fax, sorting, and identifying incoming requests. The Intake Specialist will be responsible for following up with providers to obtain clinical information on UM requests.  This role may also work with members on redirecting to in-network providers as per health plan coverage guidance.  Duties will include verifying plan coverage/PCP, securing patient demographics, requesting physician, current health status including clinical history/physical information, and requested procedures. The Intake Specialist will be responsible for recording authorization information into the database accurately and efficiently and will utilize computer software to input data. The Intake Specialist will be responsible for reviewing, triaging, and processing authorizations for accuracy and completeness of information within the database in accordance to all compliance and regulatory requirements. The Intake Specialist will communicate authorization information to appropriate individuals within the specified timeframe, inclusive of internal and external Excellent customer service in handling any internal or external communications * required for inbound and outbound calling from and to providers/ and or members. The Intake Specialist will effectively communicate results to management, and internal and external clients, and maintain a positive attitude while working in a dynamic, fast-paced environment.

ESSENTIAL DUTIES AND RESPONSIBILITIES

This position must be able to:

Authorization Request Processing:

• Perform a high level of data entry with minimal errors.  Ensure the overall data integrity of documents received are entered into the computer system accurately.
• Provides timely oral and /or written notification of determination to provider and member.
• Ability to multi-task and pay attention to detail in an environment with frequent interruptions.
• Ability to meet and maintain productivity metrics.
• Responsible for routing/processing all Out-of-network (OON) requests and following the appropriate redirection process for clinical team preparation of denials.
• Supports UM Clinical staff in obtaining clinical information, status of requests, and status of admission & discharge.

Regulatory Compliance:

• Responsible for appropriately utilizing HTA’s PAL (prior authorization list) non-clinical algorithms, network tier structure/exceptions, and preauthorization requirement by the health plan for initial preauthorization of services.
• Responsible for following all compliance and regulatory requirements for turn-around time, notification to provider/member, accuracy/completeness, and maintaining HIPAA (Health Insurance Portability and Accountability Act).

Customer Service

• Demonstrate a high level of critical thinking and detail orientation.
• Handle a high level of inbound and outbound phone calls with excellent customer service.  Be responsible for meeting call metrics set by the health plan to include length of call, length of answer time, and number of calls taken within a specific period.
• Responsible for supporting any assigned special projects pertaining to UM functions, customer service, and utilization management.
• Performs other duties as assigned

EDUCATION AND EXPERIENCE 

Education:

• Associate degree or equivalent education and/or work experience.

Required Experience:

• 1 year full-time in a healthcare office setting
• Annual Flu Vaccine

Preferred Experience:

• Working knowledge and ability to apply professional standards of practice in the work environment.
• Knowledge of specific regulatory, and managed care requirements.
• Data entry accuracy.

Excellent typing skills and phone etiquette.

PHYSICAL REQUIREMENTS

• Exerting up to 10 pounds of force occasionally (up to 1/3 of the time) and/or;
• a negligible amount of force frequently (1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time.
• Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.
• Exerting up to 20 pounds of force occasionally (up to 1/3 of the time), and/or;
• up to 10 pounds of force frequently (1/3 to 2/3 of the time), and/or:
• a negligible amount of force constantly (2/3 or more of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Even though the weight lifted may be only a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible
• Exerting 20 to 50 pounds of force occasionally (up to 1/3 of the time), and/or;
• 10 to 25 pounds of force frequently (1/3 to 2/3 of the time), and/or
• Greater than negligible up to 10 pounds of force constantly (2/3 or more of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Exerting 50 to 100 pounds of force occasionally (up to 1/3 of the time), and/or;
• 25 to 50 pounds of force frequently (1/3 to 2/3 of the time), and/or;
• 10 to 20 pounds of force constantly (2/3 or more of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Exerting in excess of 100 pounds of force occasionally (up to 1/3 of the time), and/or;
• in excess of 50 pounds of force frequently (1/3 to 2/3 of the time), and/or;
• in excess of 20 pounds of force constantly (2/3 or more of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.

Benefits from Day One: 

• Medical, Dental, and Vision Coverage
• 401(k) Retirement Plan with Company Match
• Paid Time Off (PTO) and Volunteer Time Off (VTO)
• Paid Company Holidays
• Health Savings Account (HSA) and Flexible Spending Account (FSA) Options
• Long-Term and Short-Term Disability Coverage
• Employee Assistance Program (EAP) for Personal and Professional Support
• Tuition Assistance for Continued Education
• Pet Insurance for Your Furry Family Members
• Ongoing Professional Development and Training Opportunities
• And an array of additional benefits designed with you in mind.

ABOUT HEALTHTEAM ADVANTAGE

HEALTHTEAM ADVANTAGE is an equal-opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.

HealthTeam Advantage (HTA), a Greensboro-based health insurance company, offers Medicare Advantage plans to eligible Medicare beneficiaries in 11 North Carolina counties. HTA has been named a “Best Places to Work” finalist three times by Triad Business Journal.To learn more, visit HealthTeamAdvantage.com.