Medical Services Associate

Overview

Responsible 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, physician's staff, claims staff, injured employees, policyholders, information systems to assure adherence to the LWCC's Utilization Review Policy and procedures.

Major Areas of Accountability

• Manages 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 decisions.
  • Routes 1010s to Genex (external) or internal nurses based upon internal guidelines and assignment criteria.
  • For routine office visits without compensability issues, routes 1010s to CSRs to approve and handle.
• Reviews 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 required.
• Negotiates 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 worker’s family.
• Arrange and oversee Ancillary Medical Services through approved vendors, ensuring timely communication with all parties involved.
• Functions 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 needed.
• Review 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 handle.
• Provides 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 systems.
• Develop cross-training plan for selected staff to guarantee seamless coverage.
• AMS and Pharmacy management projects as assigned by the Supervisor.

Personality/Working Style

• Strong character
  • Alignment with company values, mission, and vision
  • Trustworthy and honest
  • Decisive
  • Curious and persistent
• Passion for innovation
  • Willingness to learn
  • Adaptive to changing (tolerance for ambiguity)
  • Desire to collaborate to achieve corporate goals
• Strong communicator
  • Effective communication skills
  • Empathetic listener and open-minded
  • Commitment to accountability

Education and Experience

•  Bachelor’s degree required

Or

•  H.S. Diploma/GED with 5 – 7 years’ prior experience in healthcare services, claims services, or pharmacy environment.

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