Healthcare Review Specialist

Job Description

Job DescriptionSalary: 52,500.00 per year

MMRO's Healthcare Review Specialist is responsible for the lifecycle of healthcare claims; including but not limited to, receiving the initial request, reviewing the case for service type and conflict of interest, confirming the appropriate paperwork, creating the report template for the Physician, referring for a medical appointment, calling claimants to get information and/or to give the determination/claim outcome.

Experience that will help you excel in this role: organization, detail oriented, familiarity with medical terminology, scheduling medical appointments, customer service experience and medical office experience.

If you have industry knowledge of healthcare claims, workers comp, short term disability, long term disability or RX claims, that is beneficial.

MMRO seeks new team members who are reliable, punctual, detail oriented, respectful and contribute to a positive workplace culture.

This position works 8am to 4pm EST in our Novi office and rotates on-call weekends/holidays/evenings as needed for urgent cases.

Role and Responsibilities

• Create the new case in the case management software, as applicable.
• Create various required letters based on service type and determines the date to be scheduled for review by the PR.
• As applicable to the HCR service type, assist the CNR in obtaining additional information as requested from the client. Upon receipt of the additional information needed, notifies the CNR the additional information has been obtained.
• Maintain communication, including but not limited to any delays in service, with the referring party as required for the service type being performed.
• When scheduling a case, select the appropriate PR to complete the service type, using the following selection criteria:
• Availability to requested timeframe
• Pricing relative to client pricing thresholds
• Maintain communication with the PR (as applicable) during the review process to ensure timely and accurate delivery of the review service being completed.
• Maintain policy and process requirements for all service types, including the submission of all required correspondence and documentation consistent with state and/or client requirements.
• Accurately and consistently document all required case activities in the case management software.
• Once QA is complete, finalizes the report and delivers it to the appropriate parties.
• Accurately inputs PR cost and client charge for invoicing/payment by the Accounting Department.
• Seeks the advice of the CNR and/or direct supervisor, as needed, when performing assigned duties.
• Protects confidential patient information in compliance with the corporate confidentiality policies.
• Other duties as assigned.

Required Qualifications and Education

• High School diploma or GED
• A minimum of two (2) years related experience
• Excellent verbal and written communication skills
• Excellent customer service skills
• Working knowledge of Microsoft Office word processing and data base software
• Knowledge of medical terminology
• Ability to prioritize tasks and work independently

Preferred Skills and Additional Experience

• Advanced computer skills including data entry skills
• Prior experience in independent review operations
• At least one-year experience performing telephonic customer service support and data entry, in a medical/clinical environment
• Experience in applying general office policies and procedures and handling of confidential information
• Ability to work well under pressure, and ability to meet multiple and sometimes competing deadlines

ADA Requirements

Physical/Mental Demands:

Normal office environment. Stressful conditions may arise when workload becomes more demanding than normal. The physical requirements of the job are considered Sedentary Work per the U.S. Department of Labor, which is work involving the exertion of up to 10 pounds of force occasionally or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.Sedentary Workinvolves sitting most of the time but may involve walking or standing for brief periods of time.

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Professional development assistance
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday
• On call

Work Location: In person