"Alerted.org

**Facility:** Corporate Offices

**City** San Diego

Department

Job Status

Regular

Shift

Day

FTE

1

Shift Start Time

Shift End Time

Hours** **:

Shift Start Time:

8 AM

Shift End Time:

4:30 PM

AWS Hours Requirement:

8/40 - 8 Hour Shift

Additional Shift Information:

Weekend Requirements:

No Weekends

On-Call Required:

No

Hourly Pay Range (Minimum - Midpoint - Maximum):

$25.310 - $31.640 - $37.970

The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.  The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

What You Will Do

To provide support service, education, research and informational support to both internal and external customers of Sharp Community Medical Group.

Required Qualifications

+ High School diploma or equivalent

+ 3 years' experience working in the managed health care field with exposure to patient issues including claims, eligibility, appeals, and benefit level determination.

+ 1 year experience working in a high-volume call center.

Essential Functions

+ Collect and compile utilization dataDevelop systems to collect and compile data to assist Utilization Management department in the analysis of medical practice patterns and compliance patterns and utilization policies and procedures.

+ Customer serviceHandle incoming calls providing prompt and courteous responses to customers. Maintain a grade of 100%.Triage phone calls from providers, health plan members and health plans.Use the Customer Service Computer Module to record and track all member, provider, and health plan issues.Ensure timely follow-up on all issuesPerform Service Recovery - Apologize, Correct, Track and Take Action.

+ General supportPerform all other duties as assigned.

+ LiaisonResearch and advise on the status of claims adjudication, eligibility referrals, and appeals.

+ Maintaining relationshipsDevelop and maintain good working relationships with claims department for claims adjustments and issue resolution. Work with Health Services Management department on authorization issues, and ensure prompt response to providers of appeals, quality and eligibility issues.

+ Patient educationDevelop educational programs to educate providers on, referral process and status, benefit and claims status, in and out-of-area emergencies, physician selection and eligibility processes.

+ ResearchApply principles and knowledge of utilization management, community standards and health plan benefits.Create and make determinations on authorizations for medical services in coordination with Health Services Management Dept.Educate office staff and providers on the appeal process.

Knowledge, Skills, and Abilities

+ Excellent organizational and time management skills, good concentration skills and excellent verbal skills on the telephone and written communication skills.

+ Proficiency in medical terminology and basic knowledge of medical treatment regimens and standards of practice Knowledge of Health Plan Benefits Computer skills ---- Data input and look up skills in IDX preferable.

+ Advanced ability to work independently in research and decision making

+ Ability to sit for extended periods of time with typing/input speeds equivalent to 35 - 40 wpm.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class