INTRODUCTION

American Specialty Health Incorporated (ASH) is seeking an Examiner to join our Medical Necessity/Benefits Administration department.

The primary function of this position is to enter data from Medical Necessity Review Form (MNR Form) and Clinical Quality Evaluator (CQE) worksheets. Training on ASH Company Culture and Values; MNA Department SOPs; IHIS, ASHCore, ELIG, Other ASH Company Software Applications; Processing requirements for Medical Necessity Review Forms.

Remote Worker Guidelines

Candidates who are selected for this position will be trained remotely and must be able to work from home (WFH) in a designated work area with company-provided technology equipment. This remote/WFH position requires you have a stable connection to your Internet Service Provider with the ability to participate by video in online meetings over a reliable and consistent network (minimum internet download of 50 Mbps and 10 Mbps upload speed. 100 down/20 up is recommended to support higher quality video meetings).

Responsibilities

• Enters data from MNR Form and/or CQE worksheets. Employee must maintain a minimum level of production of 20 MNR Forms per hour and maintain quality at or above 98.0%. Employee must process a minimum level of back end treatment forms as required.

Front-end data entry:

• Reviews MNR forms to be sure all information is complete. Verifies member eligibility and creates patient records.
• Checks patient and provider information on MNR Forms against information on the eligibility tape in the Integrated Health Care System (IHIS).
• Inputs all required data from MNR forms into Integrated Health Care System (IHIS) in accordance with MNA guidelines.
• Including but not limited to Out of Network: Administrative Partial and Complete Denials.
• Submission Timeframe Denials.
• Network Access Denials.
• Forwards MNRs to the Clinical Quality Evaluators for medical necessity verification.

Back-end data entry:

• Retrieves patient files or history for the CQEs as necessary.
• Reviews CQE’s worksheets to make sure they are complete.
• Inputs all required data from worksheets into Integrated Health Care System (IHIS).
• Processes CQE worksheets in accordance to the MNA guidelines.

• Forwards worksheets to the Administrative Support staff for final processing.

• Additional Examiner Skills / Tasks

• Demonstrates proficiency in eligibility verification, provider verification, identifying and pre-screening different form types.
• Add new members and sequence numbers in Member Maintenance.
• Researches via ASHCore logs.
• Performs production query via Reports Manager.
• Forwards eligibility research to Membership.

• Process Duplicate request.

• Administrative Duties

• Contact provider’s office to clarify missing or illegible information on the MNR forms.

• Completes daily tally sheets and production reports for Supervisor.

• Performs other duties as assigned.

• Complies with all policies and standards.

Qualifications

• High School Diploma or GED certificate required.
• 2 years of data entry experience (10,000 keystrokes per hour - minimum) and working knowledge of the computer keyboard required.

Core Competencies

• Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.
• Ability to display excellent customer service to meet the needs and expectations of both internal and external customers.
• Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.
• Ability to effectively organize, prioritize, multi-task and manage time.
• Demonstrated accuracy and productivity in a changing environment with constant interruptions.
• Demonstrated ability to analyze information, problems, issues, situations, and procedures to develop effective solutions.
• Ability to exercise strict confidentiality in all matters.

Mobility

Primarily sedentary, able to sit for long periods of time.

Physical Requirements

• Ability to see, speak, and hear other personnel and/or objects. Ability to communicate both in verbal and written form. Ability to travel within and around the facility or Work from Home (WFH) environment. Capable of using a telephone, computer keyboard, and mouse. Ability to lift up to 10 lbs.

Environmental Conditions

Work-from-home (WFH) environment.

American Specialty Health is an Equal Opportunity/Affirmative Action Employer.

All qualified applicants will receive consideration for employment without regard to sex (including pregnancy, childbirth, related medical conditions, breastfeeding, and reproductive health decision-making), gender, gender identity, gender expression, race, color, religion (including religious dress and grooming practices), creed, national origin, citizenship, ancestry, physical or mental disability, legally-protected medical condition, marital status, age, sexual orientation, genetic information, military or veteran status, political affiliation, or any other basis protected by applicable local, federal or state law.

Please view Equal Employment Opportunity Posters provided by OFCCP here.

If you are a qualified individual with a disability or a disabled veteran, you have the right to request an accommodation if you are unable or limited in your ability to use or access our career center as a result of your disability. To request an accommodation, contact our Human Resources Department at (800) 848-3555 x6702.

ASH will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the Company's legal duty to furnish information.

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