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Medical Coordinator

Job Introduction

Evaluates pre-authorization requests and claims, makes decisions on payment or denial of claims within preset limit. Coordinates patient care including verification of benefits, pre-authorization for procedures and steers care to network provider or negotiates fees for off network care.

Role Responsibility

  • Manages claim requests, notification, preauthorization and eligibility questions via phone and email from Member, Producers, Providers, Physicians or authorized third party for assigned region; handles within given deadline and service objectives.
  • Reviews claims against policy to determine coverage and exclusions, reads physician information and decides compensability; may request additional information such as medical records to assist in decision making.
  • Makes decision on need for second opinion, obtains and issues authorization.
  • Sends letters of authorization or denial and explanations of benefit depending on outcome of claim evaluation.
  • Coordinates benefits eligibility, co-pays, exclusions, and determines need for second opinions, Physician or facility referral, and need for admission for care.
  • Negotiates rates with physicians or third parties outside the network utilizing usual and customary rates for specific country to ensure cost effectiveness of treatment.
  • Schedules appointments for Policy holders coming to the United States for treatment or Doctor’s appointment.
  • Evaluates patient condition and verifies that criteria required is met for air transfer, obtains authorization and coordinates air transfer if needed.
  • Enters notes for every conversation, email and decision in the system so that it is available company wide.
  • Performs follow up calls after procedure to determine if further care is needed.
  • May perform other functions as assigned by Regional Director or Medical Director.

The Ideal Candidate

  • 4 year College Degree preferred or relevant experience.
  • Minimum 4 years experience with Medical billing, coding and terminology.
  • Solid 2-3 years experience in Health Insurance Claims Service area with demonstrated experience in claims processing.
  • Previous experience1-2 years in customer service preferred.
  • Bilingual Spanish/English, fluently read, write and speak both languages.
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