Care Review Processor I

Job Title: Care Review Processor I Location: 100% Remote ( Must reside in FL, GA, ID, IA, KY, MI, NE, NM, NY (outside greater-NYC), OH, TX, UT, WA (outside greater-Seattle), WI.) Duration: 03+ months (possible extension) Must work Monday-Friday 8 am - 5 pm PST Job Description: · Must have Managed care and prior authorization experience · Clerk faxes received, load shells for authorizations · Works within the Care Access and Monitoring (CAM) team to provide clerical and data entry support for Client Members that require hospitalization and/or utilization review for other healthcare services. · Checks eligibility and verifies benefits, obtains and enters data into systems, processes requests, and triages members and information to the appropriate Health Care Services staff to ensure the delivery of high quality, cost-effective healthcare services according to State and Federal requirements to achieve optimal outcomes for Client Members. Essential Functions: · Provide computer entries of authorization request/provider inquiries by phone, mail, or fax. Including: o Verify member eligibility and benefits, · Determine provider contracting status and appropriateness, o Determine diagnosis and treatment request o Assign billing codes (ICD-9/ICD-10 and/or CPT/HCPC codes), o Determine COB status, · Verify inpatient hospital census-admits and discharges, · Perform action required per protocol using the appropriate Database. Respond to requests for authorization of services submitted to CAM via phone, fax and mail according to Client operational timeframes. · Participates in interdepartmental integration and collaboration to enhance the continuity of care for Client members including Behavioral Health and Long Term Care. · Contact physician offices according to Department guidelines to request missing information from authorization requests or for additional information as requested by the Medical Director. Provide excellent customer service for internal and external customers. · Meet department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores. · Notify Care Access and Monitoring Nurses and case managers of hospital admissions and changes in member status. Meet productivity standards. Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA). Participate in Care Access and Monitoring meetings as an active member of the team. Meet attendance guidelines per policy. Follow Standards of Conduct guidelines as described in HR policy. Comply with required workplace safety standards.

Created: 2025-09-25