Medical Determination Specialist

Who We Are

Zion HealthShare is a nonprofit medical cost-sharing program that provides an organized structure for members to contribute toward each other's medical costs.

We offer individuals and organizations across the country an affordable alternative to insurance; this provides peace of mind.

Our goal is to be America's leading HealthShare. We strive to meet our members' needs on a personal level by following our core values : inclusive, transparent, simple.

Everything we do for our members is to ensure they feel respected and to let them know we truly care about their needs.

Position Summary :

Are you someone who holds either an MA or LPN that wants to work in a fun, fast paced environment with the flexibility to select from different shifts?

Then this maybe the perfect opportunity. You will play a vital role to our community by making important decisions for a broad spectrum of medical specialties and conditions.

These determinations are based on an established set of guidelines regarding what is eligible for payment. Your ability to work efficiently and in a team setting will be vital to the overall success of Zion HealthShare.

Essential Duties and Responsibilities :

• Evaluate all Medical Need Submissions received from members to determine eligibility (aka adjudicator) for sharing into medical expenses.
• Communicate effectively and consult with members, providers, and team members as necessary throughout the determination process.
• Keep members and providers informed and updated about medical needs through regular verbal and written communication.
• Act with a sense of urgency in making determinations on medical needs.
• Maintain HIPAA compliance and company compliance policies.
• Takes inbound and outbound phone calls from members and providers regarding questions or concerns with the eligibility determination.
• Providers support to email inbox management.
• Assists with requests and following up on obtaining medical records.
• Continuously strive to exceed member expectations ensuring a high level of member satisfaction.
• Provide recommendations to the Member Guidelines Committee as needed.

Required Skills and Abilities :

• Professional level of written and verbal communication that demonstrates directness, compassion, and empathy
• Microsoft Office Suite Proficiency
• Ability to read and interpret medical records
• Ability to work effectively within a team
• Sincere desire to help other people
• Time Management
• Attention to detail

Required Education :

Minimum Requirement - Utah Medical Assistant (MA) license

Experience preferred :

• Minimum of 3+ years relevant medical records and medical terminology experience
• Working knowledge of healthcare industry, policies, and guidelines
• Experience working with and interpreting medical bills, statements, receipts, and medical records
• Familiarity with HIPAA
• Experience or familiarity in working from a CRM (Customer Relationship Management) system
• Spanish Speaking

Physical Requirements :

• Sit for up to 8 hours a day and look at dual computer screens
• Type on a keyboard at a minimum of 45 WPM

Benefits :

• Medical, dental, and vision insurance
• 401(k) plan with company match
• Paid time off (PTO)
• Short-term disability insurance
• Life Insurance
• Paid holidays

Job Posted by ApplicantPro