HealthHelp - Clinical Review CSR

  • 16945 Northchase Dr, Houston, TX 77060, USA
  • Employees can work remotely
  • Full-time

Company Description

HealthHelp - A WNS Company (www.HealthHelp.com), is the leader in the field of healthcare utilization & care management. We have gained this position by actively working to change out-of-date practices with a collaborative, non-denial based approach. Our methodology helps payors achieve a higher return on investment, gives providers education programs that better inform physicians, and ensures quality and safety for the patients needing treatment.

HealthHelp’s innovative approach and strong IT capability in specialty benefits management means that staff will move healthcare forward when provided with evidence-based solutions and second opinions. HealthHelp's staff is comprised of healthcare professionals who make a difference every day. HealthHelp has a desire to fill their company with talented and innovative people who want a career path filled with success and personal growth.

Our specialty benefits management services are broad and include, Cardiology, Oncology, Radiology, Radiation Therapy, Sleep Care, and Musculoskeletal Care. HealthHelp has two locations in Houston, one a corporate office and the second a state-of-the art contact center. HealthHelp is also proud to have another such contact center in Albany, New York.

WNS (Holdings) Limited (NYSE: WNS) is a global Business Process Management (BPM) leader. WNS offers business value to 400+global clients by combining operational excellence with deep domain expertise in key industry verticals, including Banking and Financial Services, Consulting and Professional Services, Healthcare, Insurance, Manufacturing, Retail and Consumer Packaged Goods, Shipping and Logistics, Telecommunications, Travel and Utilities.

Job Description

Provides administrative support to the Clinical Review Department
Provides quality customer service through interaction with both internal and external customers
Retrieves faxes in clinical fax rooms to enter confidential information received from provider offices ensuring the highest level of confidentiality in all areasSplitting faxes
Generate authorizations from EDI system
Verifying and entering member and facility eligibility
Escalates all calls to a Clinical Reviewer or Supervisor per guidelines as necessary when making outbound calls
Assist with queue management and monitoring for compliance requirements
Make outbound calls to provider offices to request clinical information for coordination of review by a Clinical Reviewer
Assist with monitoring and routing incoming provider calls
Assign expedited requests to Clinical Review team members to ensure a reasonable turnaround time
Reinitiate cases for Clinical Review Nurses and Peer Reviewers
Assist the UM team with administrative documentation, e.g. grids, reportsAssist with closure of Recommendation for Final Determination cases – Administrative portion of affirmation documentationAdministrative portion of other provider notifications related to authorization status
Maintains written documentation according to HealthHelp’s documentation policy
Participates and understands scope of responsibility pertaining to ongoing QI Projects
Adheres to all HIPAA, state and federal regulations pertaining to the clinical programs
Adheres to both URAC & NCQA standards pertinent to their job description
Carries out other projects and responsibilities as assigned
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Qualifications

Proficiency with medical terminology highly desirable
Microsoft Office (e.g. Excel, Word), Outlook (e.g. email & calendar), and Windows proficiency
High School Diploma
Associates Degree (preferred)
Medical assistant or other clinical or medical office experience highly desirable
At least one year of Call Center experience
At least 2 years of Customer Service experience
Highly skilled at delivering client and customer satisfaction
Must possess strong verbal and written communication skills
Ability to read and comprehend complex documents

Additional Information

All your information will be kept confidential according to EEO guidelines.

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