Title: Health Services Support Coordinator

Reports to: Director of Health Services

Description:Performs a variety of duties for the Health Services Department, including but not limited to, processing requests for services from members and providers, member eligibility confirmation and coverage of benefits verification. Assisting Case Managers in requesting clinical information from providers as needed. Complies with all standard operating procedures, and all departmental and organizational policies. Meets and exceeds minimum benchmarks established for the role.

Essential duties and responsibilities, but are not limited to:

• Receives requests for prior authorization for services by phone, fax or electronically.
• Reviews and evaluates requests for completeness as follows:

• Required information for processing;
• Eligibility confirmation;
• Benefit level verification for limitations/exclusions;
• Coordination of benefits;
• Appropriate physician documentation of referrals;
• Check for duplicity of requests

• Sorts requests by urgency or as the member’s health requires, and notifies/distributes accordingly.
• Creates the requests in the Plan’s authorization system.
• Assures all required information in the prior authorization request is included in the authorization.
• Contacts providers and non-par physicians to obtain the necessary information to make a coverage determination and documents all in the authorization.
• Facilitates access to specialist and therapies when required .
• Coordinates care across settings and providers for certain services .
• Forwards all requests that require additional clinical review to determine medical necessity criteria to the utilization review nurse determination.
• Finalizes the request of services in the system.
• Notifies the member and/or provider by phone, fax, e-mail or letter per protocol.
• Answers all department incoming calls in a polite and professional manner.
• Works on a variety of special projects and assumes other duties as assigned by the Director of Health Services or designee.
• Adheres with HIPAA regulation and departmental policies and procedures.
• Participates in workshops and trainings.
• Assists in the training of other employees as needed.
• Promotes quality customer and provider service through team efforts.
• Exhibits flexibility, sensitivity and respect, maintaining a working relationship with all company staff.

Education and experience:

Required: High school graduate with at least six months to one year experience, education and/or training in the health care or managed care field.

Preferred: Associate's Degree in Health or Business Administration or equivalent from a two year college or technical school. Medical terminology course desirable.

General skills and requirements:

• Excellent customer services skills.
• Computer literate in Microsoft Windows applications, software and Internet.
• Possess excellent phone, computer, and organization skills.
• Must be flexible and a team player.
• Ability to analyze data and make recommendations for improving the work processes as appropriate.

Language skills:

Ability to speak, read and write in English required. Bilingual (Spanish/English) preferred. Ability to read and understand instructions, procedures, policies and other types of written communication. Ability to effectively present information in one-to-one and small group settings to customers and internal staff.

Working conditions:

Requires sitting and standing associated with a normal office environment. Perform tasks requiring independent knowledge and judgment in addition to instructions and procedures provided. Must be able to function with frequent interruptions, accept change and able to prioritize activities when faced with competing demands. A flexible schedule which could involve evening and weekend work depending on department needs