Job Description

General Purpose of Job:

The Medical Benefit Coordinator position is integral to the overall function of the Utilization Management team. This position is responsible for the daily support of the Utilization Management team, processing non-clinical requests for care, as well as communication with providers, members, and other Health Plan staff.

Essential Duties:

This job description is intended to cover the minimum essential duties assigned on a regular basis. Associates may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.

• Processes internal and external non-clinical reviews using guidelines, policies and procedures.
• Maintains knowledge of PHP networks and redirects members to network providers appropriately.
• Collects minimum necessary information from health care providers to complete benefit determinations.
• Responds to incoming calls from internal and external customers.
• Conducts claims review to determine benefit limits.
• Assures accuracy of claims payment by identifying and confirming correct coding per industry standard.
• Meets timelines and follows policies and procedures in accordance with regulatory bodies, accreditation standards, and PHP requirements.
• Understands and navigates member coverage documents to ensure benefits are applied appropriately.
• Actively participates in team and departmental meetings to improve processes and increase department efficiency.
• Follows departmental Standard Operating Procedures to complete work accurately.
• Seeks out and obtains input from peers, clinical staff, Supervisor, and/or Manager appropriately.

Job Requirements

General Requirements	None
Education	Associates degree in a healthcare related field or high school diploma with at least 3 years of experience in a managed care environment
Specialized Knowledge and Skills	Experience in a fast-paced work environment that changes rapidly. Excellent oral and written communication skills Computer proficiency including Microsoft Word, Microsoft Outlook, Microsoft Excel Knowledge of ICD-10, HCPCS and CPT coding and medical terminology Excellent time management skills and ability to prioritize multiple tasks Strong background in the healthcare or insurance industry, preferred