Cost Utilization Specialist
Location: Lees Summit, Missouri
Description: GEHA, Inc. is in need of Cost Utilization Specialist right now, this job will be designated in Missouri. Further informations about this job opportunity kindly read the description below. EOE M/F/D/V
Number of Positions: 2
Summary
Coordinates, reviews and investigates claims to determine the medical necessity and appropriateness of the care given in relation! to the diagnosis and contractual provisions of the plan in relation to each case. Directs processing of these contractual benefits after investigation is complete. Negotiates and coordinates cases with health care professionals to achieve discounts. Engages and educates members about Care Management programs, additional resources, and GEHA services. Identifies cases for internal and external care management/cost-containment programs. Documents case information in appropriate systems.
Duties Include...
- Reviews exception claims received from claims sections. Reviews claims for procedures inconsistent with diagnosis or beyond normal fee guidelines. Analyzes claims to determine medical necessity, reasonable and customary pricing, potential cosmetic procedures and unbundling of services. Determines benefit allowances based on contract liability and consultant recommendations.
- Investigates claims requiring additional information, contacting provide! rs and/or vendors for medical records or additional informatio! n as needed.
- Determines which cases require consultant and Medical Director review or assignment to Care Management Nurse. Makes recommendations to the Medical Director or Care Management Nurse.
- Analyzes consultant and Medical Director recommendations. Determines if review and opinion comply with contract provisions and cost guidelines. Instructs claim sections on correct benefit determination and explains consultant and Medical Director's review and opinion.
- Responds to providers of medical care, members, attorneys, and State Boards. Provides input for OPM reply on disputed claims. Writes all correspondence required for each case except pre-authorizations giving approval. Explains denial of benefits by phone and letter.
- Investigates new technologies to determine if they meet contract provisions. Contacts centers of medical excellence and control such as major university teaching hospitals, the National Institute of Health, or the Nationa! l Cancer Institute to gather information. Documents findings and forwards to Administrator.
- Investigates providers whose billing and/or practices indicates over-utilization, excess fees and poor standards of medical care. Documents findings, makes recommendation for option three designation.
- Negotiates with vendors and providers for price discounts to achieve cost effectiveness. Forwards appropriate cases to National contract vendors as appropriate.
- Assists Claim Managers and supervisors on cases as needed
- Assists with Care Management Nurses workload by handling non-clinical duties and documenting in appropriate system. Examples: negotiation of equipment or services, non-complex drug repricing and other program-specific duties.
- Assists members with contacting providers, community agencies, other Care Management professionals, and other GEHA services.
- Identifies cases for internal and external care management/cost-contain! ment programs.
Requires two years! (60 hours) of college. Additional years of qualifying work experience may be considered in lieu of formal education.
Experience Requirements
Requires two years experience in health insurance or health care setting that includes knowledge of medical claims processing. Requires knowledge of MS Excel and MS Word. Requires effective written and verbal communication skills to create letters regarding complex medical situations, negotiate with providers, coordinate complex medical situations and communicate with GEHA management, employees, members and health care professionals.
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If you were eligible to this job, please send us your resume, with salary requirements and a resume to GEHA, Inc..
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This job will be started on: Wed, 26 Jun 2013 09:39:34 GMT
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