Care Management Associate I - New York, NY
Company: MetroPlus
Location: New York
Posted on: March 20, 2023
Job Description:
Empower. Unite. Care.MetroPlusHealth 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.About NYC Health +
HospitalsMetroPlusHealthprovides the highest quality healthcare
services to residents of Bronx, Brooklyn, Manhattan, Queens and
Staten Island through a comprehensive list of products, including,
but not limited to, New York State Medicaid Managed Care, Medicare,
Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold,
Essential Plan, etc. As a wholly-owned subsidiary of NYC Health +
Hospitals, the largest public health system in the United States,
MetroPlusHealthnetwork includes over 27,000 primary care providers,
specialists and participating clinics. For more than 30 years,
MetroPlusHealthhas been committed to building strong relationships
with its members and providers to enable New Yorkers to live their
healthiest life.Position OverviewThe 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.Job
Description
- Receive service requests from providers and members via
facsimile, provider portal, phone, and mail
- Receive 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 benefits
- Strive to provide first-call resolution to all callers
- Provide superior customer service to all providers and
members
- Verify member eligibility and benefits utilizing the MIS system
and/or ePACES.
- Create and/or complete an authorization shell, 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
services
- Receive and process inbound correspondence to ensure it is
associated with the correct member and contains adequate
information for clinical review
- Refer to RN or MD as indicated
- Generate denial letters which relate to the member's
ineligibility for services when appropriate
- Follow guidelines for services which can be approved by the CMA
under the direction of the Medical Director
- Generate 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 codes
- Work efficiently and diligently and meet minimal required
performance expectations and quality requirements
- Assist 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 activities
- Perform other duties as assigned.Minimum Qualifications
- High School diploma or GED (General Equivalency Diploma)
- 1 to 3 years of experience in an administrative support role in
either Utilization Management or Appeals
- Understanding of medical terminology including ICD-10 and CPT-4
codes preferred
- Call center or Customer Service experience preferred
- Skilled in using a computerProfessional Competencies
- Integrity and Trust
- Customer Focus
- Functional/Technical Skills
- Written/Oral Communications
- Strong work ethic
- Efficiency and attention to detail
- Ability to research on the Internet
- Ability to communicate in English clearly
Keywords: MetroPlus, New York , Care Management Associate I - New York, NY, Executive , New York, New York
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