Medical Services Associate

OverviewResponsible for review of all correspondence arriving in the Utilization Review (UR) email box and routes material accordingly. Responsible for first level reviews of the Durable Medical Equipment (DME) and Ancillary Medical Services (AMS) Utilization programs and coordination of all associated activities. Also responsible for first level reviews of the pharmacy management program and coordination and routing of all associated activities. Duties include but are not limited to working with the DME Vendors medical service providers Pharmacy Benefits Manager (PBM) pharmacists physicians staff claims staff injured employees policyholders information systems to assure adherence to the LWCCs Utilization Review Policy and Areas of AccountabilityManages the UR email box. Routes non-UR claims material to the appropriate party. Reviews 1010s to determine appropriate action:Routes 1010s to reps for issues related to compensability body parts and treating physician. Ensures timely turnaround for compliance with the 5 days regulatory timeline for 1010s to Genex (external) or internal nurses based upon internal guidelines and assignment routine office visits without compensability issues routes 1010s to CSRs to approve and requests requiring prior authorization of prescriptions for Durable Medical Equipment (DME) ancillary medical services (AMS) and Pharmacy. Follows Utilization Review guidelines for claims with DME and AMS prescriptions requiring intervention based on cost medical necessity treatment protocols or FDA Standards. Investigates appropriateness of all prescription requests securing medical information from the claims file claims staff prescribing physician and pharmacist. Prepares claims information and reviews questionable cases with supervisor or the Medical Director. Communicates approval or denial information to injured workers physicians vendors pharmacy and other parties as one time pricing agreements for DME needs within assigned authority levels insuring that 1010 forms contain sufficient information for accurate bill processing. Coordinates the delivery of services or products with the medical provider and the injured workers or injured workers and oversee Ancillary Medical Services through approved vendors ensuring timely communication with all parties as the liaison between LWCC and the DME/AMS network. Ensures the network vendors administer program(s) consistent with contract or company requirements. Provides input on contract pricing as prescription requests requiring prior authorization including those exceeding quantity duration FDA or other limits. Route authorization requests to the proper staff for handling. Maintains log and follows up on letters of medical necessity. Routes responses to the appropriate clinical staff to unparallel customer service to all customers. Addresses problems and responds to inquiries from vendors pharmacists injured workers physicians and claims staff. Inputs updates and maintains internal and external claims information cross-training plan for selected staff to guarantee seamless and Pharmacy management projects as assigned by the StyleStrong character Alignment with company values mission and visionTrustworthy and honestDecisiveCurious and persistentPassion for innovation Willingness to learnAdaptive to changing (tolerance for ambiguity)Desire to collaborate to achieve corporate goalsStrong communicatorEffective communication skillsEmpathetic listener and open-mindedCommitment to accountabilityEducation and ExperienceBachelors degree requiredOrH.S. Diploma/GED with 5 7 years prior experience in healthcare services claims services or pharmacy environment.

Required Experience:

IC

Employment Type : Full Time
Experience: years
Vacancy: 1