Jobs for People with MS: National MS Society

Description:

Job Description: (Fast track program. Typically this job would start as a Benefit Coordinator, but we are fast tracking to Case Review) 60-120 days. Contract with medical plans to provide help with DME. They get prescriptions and request prior auths They need a bed, they get the prior auth. Benefit Coordinator will get the approval, then move on. However, if it is not approved, it is routed to Case Review Staff.

Case Review goes above and beyond. They review request and policy of the person is qualified. Review documentation, request documentation to get them approved. Then, they will write a narrative on why they qualify or do not qualify! The written part is streamlined with a template.

Lastly, they will articulate the decision to the physician and the patient.

Supporting these health plan programs: Case review is supporting out of state contract health plans, support the Blue's in Michigan! 8 health plans in total. Medicare, Medicaid HMO, Blues, state contracts, Well Sense (by state), HNE, and new one starting July 1st called Alliance.

Hours of operation and breaks: 8:30-5pm. 45 min Lunch. 2 x 10's. Paid breaks

The case review specialist is responsible for performing all tasks relevant to in-house communications with the patient/client, referral source, and verification of eligibility, co-pay and coordination of setup with providers. In addition, this person is part of the investigative team that researches product and member special needs. The Case Review Specialist conducts the initial screening for service requests, adds the collection and transfer of non-clinical data to the case, conducts acquisition of structured clinical data, and activities that do not require evaluation or interpretation of clinical information. The non-clinical staff is not responsible for conducting any UM review activities that require interpretation of clinical information including non-certification of requests.

Case review is not on the phones, as much. They will read and write for investigation to see if a member does or does not qualify. Reading through medical policies, healthcare documents, scripts, medical records and from the Medicare Plan.

They will write up a case on why or why not the person qualifies. It is more in depth from traditional customer service.

Principal Duties and Responsibilities:

Answer incoming phone calls and input customer requests for equipment according to the health plan criteria and diagnosis.

Maintain open line of communication with patients/clients, and referral sources

Respond to patient/client questions and problems.

On-line set-up of new patient/client files, verifying eligibility information and co-pays

Verification of PCP involvement in ordering equipment

Review of members address and telephone number for delivery

Reviews on-line order for completeness and accuracy before faxing order to provider for set-up

Investigate products, providers, prices and medical policies on equipment for guest members and traveling members.

Works with Utilization Management Nurse Manager/clinical staff on cases where clinical judgment is required.

Utilizes automated or semi automated processes to collect data or conduct initial screening of cases following Health Plan guidelines

Other related duties assigned by the Manager

About TEKsystems:

We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change. That's the power of true partnership. TEKsystems is an Allegis Group company.

The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.