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.
DEPARTMENT: Legal-Regulatory Affairs
REPORTS TO: Director, Product Operations
LOCATION: Rocky Point, Tampa, FL
- Utilizes WellCare 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.
- 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-9/10 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 work effectively within group to achieve desired outcomes
- Required intermediate Microsoft Outlook, Word and Excel
- Bilingual English/Spanish helpful