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Evaluates the pre-service authorization request for Durable Medical Equipment, Orthotic and Prosthetics. Performs a unique role in reviewing records, uses subject matter expertise and compares information to established guidelines and the members benefit plan. Works closely with departmental clinical staff and management staff to impact the treatment plan and identify treatment plan alternatives.
Utilizes Well Care guidelines, CMS and State criteria, Fee Schedules along with subject matter knowledge to make authorization decisions and assist Medical Director with review determinations
Ensures accurate coding using most current coding guidelines. Documents all information accurately.
Corresponds and communicates with providers, vendors, members and various Wellcare departments.
Identifies and refers cases appropriate for case management.
Identifies potential quality of care issues and refers to Quality department.
Ability to follow and apply all necessary regulatory requirements for assigned market.
Assists with implementation of health care initiatives in market.
Assist in implementation of specific strategies of quality and outcomes of care.
Performs other duties as assigned.
Additional Responsibilities:Candidate Education:
Required A High School or GED
Preferred An Associate's Degree in a related field
Required 3 years of experience in a managed care setting, medical office or facility setting with demonstration of medical administration duties
Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate Demonstrated written communication skills
Intermediate Ability to effectively present information and respond to questions from peers and management
Intermediate Ability to multi-task
Intermediate Other Work effectively within group to achieve desired outcomes
Licenses and Certifications: A license in one of the following is required: Technical Skills:
Required Intermediate Microsoft Outlook Proficient in Microsoft Office such as Outlook, Word and Excel