This position supports PEHP’s efforts to mitigate the rising cost of health care and provide excellent customer service. This position performs a variety of support duties including clinical services technical support, customer service support, and education through inbound and outbound communications. This position also collaborates with PEHP nurses, pharmacists, and doctors; provides customer service to PEHP members and network physicians; solves problems with pre-authorizations or claims and assists the Clinical Management department in pre-authorization evaluation and the disputed/appealed pre-authorization process. The successful candidate will have excellent communication skills, a basic understanding of medical terminology, understand medical claims payments, the ability to learn and apply new information, and is willing to go the extra mile to provide excellent customer service. The incumbent must always demonstrate good judgment, high integrity, and personal values consistent with the values of URS.

ESSENTIAL JOB FUNCTIONS AND DUTIES

• Acts as a member advocate to resolve member/provider insurance problems, which may be related to requests for pre-authorization of benefits, claims, and/or benefit interpretation.
• Responds to issues, questions, and concerns from PEHP members, providers, and internal customers via incoming and outgoing phone calls, written correspondence, fax, email, etc. Responds to questions regarding policy description and interpretations, payment processes, and eligibility for covered services. Assists callers in the proper procedures related to claims corrections and appeals.
• Receives and responds to incoming phone calls from policy holders, claimants, providers, pharmacies, and representatives of other insurance companies. Responds to complex questions regarding medical and pharmacy claims processing, policy descriptions and interpretations, payment processes, coordination of benefits, and eligibility of covered services.
• Educates members, providers, and pharmacies through outbound phone calls on company policies and plan benefits.
• Acts as first level review for cases being entered into the case management system.
• Assists in providing reporting regarding high dollar cases, reinsurance requirements, cost savings, outreach calls, and disease management program tracking.
• Assists in member outreach calls for disease management programs.
• Provides information on co-pay assistance programs offered through pharmaceutical manufacturers.
• Identifies requests for out-of-network services and directs care to in-network providers. Educates on out-of-network costs and potential for balance billing.
• Evaluates and determines coverage on prior authorization requests for pharmacy, medical benefits, and durable medical equipment (DME) in a timely manner.
• Prepares and collects clinical information for disputes and appeals. Forwards to the appropriate Clinical Management staff.
• Works closely with providers, vendors, and members to obtain all necessary information for pre-authorization and ensures completion in a timely manner.
• Resolves clinical issues pertaining to pre-authorizations, disputes, eligibility, mail order, benefits interpretation, and claims payments.
• Communicates pre-authorization and disputed prior authorization approvals/denials with physicians, members, PEHP Member and Provider Services department, PEHP Clinical Management department, and the PEHP Member Claims department through mailings, inbound/outbound phone calls, and the PEHP Message Center.
• Maintains and reconciles Medicare D electronic eligibility files.
• Assists in Clinical Management department mailings.
• Manages a high volume of incoming calls.
• Maintains strict confidentiality (HIPAA compliant).
• Performs other related duties as assigned.

High School diploma and three (3) years of progressively responsible experience in a medical setting (insurance, practice, facility, etc.), or an equivalent combination of education and experience.

 Certification as a Nursing Assistant (CNA), Medical Assistant (AAMA), Current Procedural Terminology (CPT), registered pharmacy technician (CPhT), or other health care related license/certificate is preferred.

 Certified Professional Coder (CPC) or medical terminology certification and or specific experience in claims processing, computer software applications, and electronic billing procedures is preferred.