Presbyterian Healthcare Services

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at Presbyterian Healthcare Services

Posted: 10/14/2020
Job Reference #: 17198
Keywords: healthcare, health

Job Description

Requisition ID
Case/Utilization Mgmt/Care Coor
Default: Location : City
Location : Name
Rev Hugh Cooper Admin Center
Default: Location : State/Province (Full Name)
New Mexico


Job Description 
Type of Opportunity: Full Time
FTE: 1.000000
Exempt: No
Work Schedule: Days

Responsible for supporting Health Services Coordination functions including, but not limited to, medical records coordination, technical retrospective claims review, referral/auth. entry, research which may include but not limited to claims, eligibility, benefits, provider contracts, coordination of benefits, provider education, data entry report generation, act as liaison to and/or assists PHS clinical leaders


Prior Authorization may process emergent/elective and transitional prior authorization requests according to established evidenced based criteria. Screens prior authorization requests not meeting guidelines and requests/gathers/forwards additional information.

May conduct utilization review by monitoring daily prior authorization requests and documenting timely updates for service requests. Completes Administrative Denials and submits Medical Director Reviews as directed.

Correspondence with Provider/Member Notifies members and providers including but not limited to approvals, provider notification of service requests and out of network approvals

Coordination of Benefits by monitoring benefit limitations for all members. Identifies members for case management or needed follow up regarding subrogation or coordination of benefits. Refers to appropriate departments as needed. Provides claims follow up as indicated.

Documents in multiple computer applications timely and according to unit policy and regulations. Documents appropriate codes and claims payment information to ensure accurate claims payment. Data entry to ensure accurate records notifications/referrals. Submits Patient referrals for complaints and compliments.

Liaison with providers and facilities telephonically, include problem solving regarding member needs, Requests clinical updates.

May respond to incoming calls routed through skill-based technology to meet quality standards and performance measurements. May conduct outbound calls as required and meet established quality/quantity guidelines supporting initiatives and/or programs.


Other information:
High School Diploma GED required. Associates Degree or completion of a medical vocational program preferred. One to three years' experience in a medical or health insurance position

Updated: 1/24/2019

* High School Diploma or GED


Competencies and skills:
* SKILL-Critical thinking and attention to detail.
* ICD 9 OR 10
* SKILL-Microsoft Office
* Demonstration of high degree of independent problem solving and critical thinking skills.
* SKILL-Ability to deal with all levels of staff and management within the organization, board members, as well as the public, under highly stressful conditions.
* SKILL-Demonstrated ability to communicate effectively in person and via telephone with members, employer groups, brokers, physicians, and physician office staff using strong dialogue and customer service competencies.

* SKILL-Written communication


Benefits are effective day-one (for .45 FTE and above) and include:
  • Competitive salaries
  • Full medical, dental and vision insurance
  •  Flexible spending accounts (FSAs)
  •  Free wellness programs
  • Paid time off (PTO)
  • Retirement plans, including matching employer contributions
  • Continuing education and career development opportunities
  •  Life insurance and short/long term disability programs

About Us
Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state's largest private employer with approximately 11,000 employees.

Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.
We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.
About New Mexico
New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences that make this state great.
Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC.
New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

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