✨ AI Summary
The Medical Case Coordinator role involves managing service approvals for insured members through various systems like DHPO, email, and PBM. This includes overriding rejected medications based on policy terms and clinical justification. The position requires providing excellent customer service by responding swiftly to inquiries from insured members and medical providers, and coordinating between insurers, patients, and providers. Key responsibilities also include handling pre-authorizations, reconsiderations, appeals, and performing comprehensive reviews of medical records to ensure all necessary components are present. Additionally, the role involves managing pharmacy rejections and approvals according to policy, and processing pharmacy and outpatient clinic claims at the end of each month.
Providing approval of services for the insured member through DHPO, email and PBM, over riding of rejected medication if falls under policy t&c and if clinically justified.Providing excellent customer service through responding swiftly to queries from insured member, medical provider .Provide approval through online system(DHPO), emails and call to Medical provider according to medical necessity and as per policy wordings.Coordinate between Insurer, patient and provider.Handles phone calls and w
Requirements
Qualifications:
Education : Bachelor of Pharmacy/Bachelor of Nursing
Experience : Insurance experience is preferred
Description
Providing approval of services for the insured member through DHPO, email and PBM, over riding of rejected medication if falls under policy t&c and if clinically justified.Providing excellent customer service through responding swiftly to queries from insured member, medical provider .Provide approval through online system(DHPO), emails and call to Medical provider according to medical necessity and as per policy wordings.Coordinate between Insurer, patient and provider.Handles phone calls and written inquiries related to requests for pre-Approvals/pre authorizations, reconsiderations, or appeals.Performs a comprehensive review for the record to assure thepresence of all component parts such as patient and record identification, signatures and dates where required and other necessary data in the presence of all reports which appear to be indicated by the nature of the treatment rendered.Handing pharmacy rejection and approving the same if matches with indications and policy wordings.Processing pharmacy and op clinics claims at the end of the every month.