Healthcare Review Specialist

MMRO's Healthcare Review Specialist is responsible for the administrative process of healthcare claims and appeals. This crucial role requires attention to detail and accurate data entry. Medical office/environment experience is a plus, including medical terminology. This role is required to rotate on an on-call schedule that may include evenings, weekends and holidays between the hours of 8am and 8pm EST. On-call work is done remotely. M-F schedule is in-office, in Novi, MI. with Wednesdays as an optional remote day.

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 Work involves sitting most of the time but may involve walking or standing for brief periods of time.