Presbyterian Healthcare Services
Location
Santa Fe, NM | United States
Job description
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
Type of Opportunity: Full Time FTE: 1.000000 Exempt: No Work Schedule: Days
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
Education:Essential:* High School Diploma or GED
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 approvalsCoordination 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.
We offer more than the standard benefits!
Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more!
Learn more about our employee benefits:
Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans. For our employees, we offer a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more.
Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 New Mexicans.
About Presbyterian Healthcare Services
Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are 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, we are the state's largest private employer with nearly 14,000 employees - including more than 1,600 providers and nearly 4,700 nurses.
Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
About Our Regional Delivery System
Presbyterian's Regional Delivery System is a network of six hospitals and medical centers throughout rural New Mexico including locations in Clovis, Espanola, Ruidoso, Santa Fe, Socorro and Tucumcari. Our regional facilities are home to more than 1,600 clinical and non-clinical employees who help make Presbyterian the state's largest private employer with nearly 14,000 statewide employees. With a variety of services ranging from general surgery to pediatrics to heart and cancer care, our regional employees are proud to provide close-to-home care for their communities.
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 continues to grow steadily in population and features a low cost-of living.
Varied landscapes bring filmmakers here from around the world to capture a slice of the natural beauty New Mexicans enjoy every day. Our landscapes are as diverse as our culture - from mountains, forests, canyons, and lakes, to caverns, hot springs and sand dunes.
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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