Care Management Associate - UM

Care Management Associate (CMA)Client is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us.

You can come to work being proud of what you do every day. The Care Management Associate I, under the direction of the Senior Director of Clinical Services, is responsible for the daily activities of the member case intake and processing functions and associated work flow, as well as for performing other duties associated with the coordination of member care as outlined and/or assigned by their Manager.Product of Role & Responsibilities:Receive service requests from providers and members via facsimile, provider portal, phone, and mailReceive in-coming calls, address the caller's needs (providers and members) and/or offer clarification on questions or concerns as related to policy & procedure and benefitsStrive to provide first-call resolution to all callersProvide superior customer service to all providers and membersVerify member eligibility and benefits utilizing the MIS system and/or ePACES.Create and/or complete an authorization Client, generating a reference number.Follow documented process flow and job aids to either process the authorization request to completion or direct request to clinical staff (Nurse or MD) for review.Initiate requests via phone/facsimile for supporting documentation to determine medical necessity of requested servicesReceive and process inbound correspondence to ensure it is associated with the correct member and contains adequate information for clinical reviewRefer to RN or MD as indicatedGenerate denial letters which relate to the member's ineligibility for services when appropriateFollow guidelines for services which can be approved by the CMA under the direction of the Medical DirectorGenerate approval letters for members and providers, where applicable, utilizing the system's correspondence module, and selecting the correct letter template according to the members line of business.Accurately document and enter data in MIS system pertaining to the services requested, including correct member, provider, and clinical information such as service dates, diagnosis codes, service codesWork efficiently and diligently and meet minimal required performance expectations and quality requirementsAssist co-workers and other staff as directed.Participate in special projects as requested or required.Participate in on-going training and staff meetings to enhance job knowledge and skills, and to offer ideas towards the enhancement of the department's processes.Participate in departmental quality improvement activitiesPerform other duties as assigned.Required Education, Training & Professional Experience:High School diploma or GED (General Equivalency Diploma)1 to 3 years of experience in an administrative support role in either Utilization Management or AppealsUnderstanding of medical terminology including ICD-10 and CPT-4 codes preferredCall center or Customer Service experience preferredSkilled in using a computerAbility to research on the InternetAbility to communicate in English clearlyProfessional Competencies:Integrity and TrustCustomer FocusFunctional/Technical SkillsWritten/Oral CommunicationsStrong work ethicEfficiency and attention to detail