Summary
Performs routine administrative workflow tasks that support functions of Clinical Operations. Engages and educates members and providers about GEHA benefits and programs. Identifies cases for internal and external Clinical programs.
Duties
- Uses various communication methods to identify and solicit information from providers and vendors as relevant to clinical and business need.
- Coordinates, reviews and investigates claims to determine the medical necessity and appropriateness of the care
- Determines simple cases that require review by Medical Director, Pharmacist or nurse.
- Interprets medical review results to determine compliance with contract provisions.
- Identifies cases for care and cost management
- Actively engages in communication and response with internal and external customers regarding care management, products, and services
- Directs processing of contractual benefits after investigation is complete
- Escalates complex cases to senior team member.
- May place calls to members and communicates barriers and opportunities identified through member outreach calls
- Ensure compliance for all quality audits and maintain all data and process controls and reports suspicions of compliance, clinical, quality, and regulation concerns
- Educates members on applicable plan benefits and service information
- May be tasked to initiate process to request and evaluate member compliance reports for HEDIS measures, including evaluating improvement opportunities.
- May be tasked with completing HEDIS quality specific projects assisting members in scheduling primary care appointments
Education Requirements
Requires two years (60 credit hours) of college or 2 years of healthcare experience, additional years of qualifying work experience may be considered in lieu of formal education.
Experience Requirements
- Requires intermediate proficiency with technology applications and systems.
- Requires experience using Microsoft office products, i.e., Outlook, Excel, Word, Teams.
- Requires effective written and verbal communication skills.
- Must be able to work Monday - Friday 9:00am - 6:00pm.
- Must reside in the Kansas City Metro
Preferred
Preferred knowledge of HEDIS and CAHPS
GEHA is an Equal Opportunity Employer, which means we will not discriminate against any individual based on sex, race, color, national origin, disability, religion, age, military status, genetic information, veteran status, pregnancy, marital status, gender identity, and sexual orientation, as well as all other characteristics and qualities protected by federal, state, or local law. We celebrate diversity and are committed to creating an inclusive environment for all employees.
