Care Management Associate I (Appeals)

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

• Receive service requests from providers and members via facsimile, provider portal, phone, and mail
• Receive in-coming calls, address the caller's needs (providers and members) and/or offer clarification on questions or concerns as related to policy & procedure and benefits
• Strive to provide first-call resolution to all callers
• Provide superior customer service to all providers and members
• Verify member eligibility and benefits utilizing the IT system and/or ePACES.
• Create and/or complete an authorization shell, generating a reference number.
• Follow documented process flow and job aids to either process the authorization request to completion or direct request to clinical staff (Nurse or MD) for review:
  • Initiate requests via phone/facsimile for supporting documentation to determine medical necessity of requested services
  • Receive and process inbound correspondence to ensure it is associated with the correct member and contains adequate information for clinical review
  • Refer to RN or MD as indicated
  • Generate denial letters which relate to the member's ineligibility for services when appropriate
  • Follow guidelines for services which can be approved by the CMA under the direction of the Medical Director
  • Generate approval letters for members and providers, where applicable, utilizing the system's correspondence module, and selecting the correct letter template according to the members line of business.
• Accurately document and enter data in IT system pertaining to the services requested, including correct member, provider, and clinical information such as service dates, diagnosis codes, service codes
• Work efficiently and diligently and meet minimal required performance expectations and quality requirements
• Assist co-workers and other staff as directed.
• Participate in special projects as requested or required.
• Participate in on-going training and staff meetings to enhance job knowledge and skills, and to offer ideas towards the enhancement of the department's processes.
• Participate in departmental quality improvement activities.
• Perform other duties as assigned.

• High School diploma or GED (General Equivalency Diploma)
• 1 to 3 years of experience in an administrative support role in either Utilization Management or Appeals
• Understanding of medical terminology including ICD-10 and CPT-4 codes preferred
• Call center or Customer Service experience preferred

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical Skills
• Written/Oral Communications
• Strong work ethic
• Efficiency and attention to detail
• Ability to research on the Internet
• Ability to communicate in English clearly
• Proficiency in using a computer

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