Community Health Network of Connecticut, Inc.

General

• Work collaboratively with Health Services’ staff in conducting medical necessity review activities for Community Health Network members
• Approve or deny services based on benefit package and medical necessity criteria
• Respond to telephonic and written authorization and benefit coverage requests from CHNCT providers
• Conduct medical necessity reviews for DME, outpatient therapies, and inpatient and outpatient procedures
• Identify coordination of benefits needs and third-party liability
• Utilize InterQual and/or Medicaid criteria to make decisions
• Select, format, proofread, and print member and provider denial letters
• Refer cases to the CHNCT Medical Reviewer when clinical information does not support medical necessity
• Assist in educating providers on CHNCT policies and procedures
• Maintain knowledge of covered Medicaid benefits and share information with clinical staff
• Identify and refer cases for Intensive Care Management evaluation
• Escalate authorization issues to the Manager for resolution
• Review non-par and non-covered service requests and approve or deny them according to guidelines and policies
• Perform other duties as assigned

Prior Authorization Coordinator

Call Center Representative

• Answer member and provider questions by telephone, written, or electronic media
• Document inquiries, grievances, caller concerns, actions taken, and call disposition
• Provide accurate and timely benefit and network information
• Verify member eligibility and provider participation
• Resolve routine member and provider concerns
• Escalate complex cases and issues to senior representatives or management
• Make assigned outbound calls and callbacks
• Assess referrals to ICM, other programs, and community resources
• Research and document inquiries and grievances promptly
• Maintain knowledge of program requirements and benefits
• Use resource materials to ensure accurate information
• Meet or exceed an average speed of answer of 90% of calls within 60 seconds
• Maintain an abandonment rate below 5% and hold times below 3 minutes
• Adhere to department standards, privacy/security requirements, and CHNCT policies
• Perform other required tasks

Prior Authorization Coordinator

Call Center Representative, Tier 1 – Temporary Assignment