The Care Coordinator supports the utilization management team by processing authorization requests and maintaining accurate referral documentation. They act as a point of contact for providers and members while ensuring compliance with HIPAA regulations.
The Managed Care Accountant assists with financial operations including billing, collections, and analysis while maintaining accurate financial records. They are responsible for capitation reconciliation, IBNR reporting, and supporting annual audits for clients.
The Medical Billing Coordinator manages outstanding claims and collaborates with insurance carriers and providers to ensure timely and accurate reimbursement. They are responsible for identifying billing issues, maintaining compliance, and documenting all interactions within the claims management system.
The UM Outpatient Review Nurse is responsible for conducting medical necessity reviews for authorization requests and ensuring compliance with clinical guidelines. They also manage the denial process, maintain quality standards, and act as a clinical resource for the team.
The Claims Recovery Examiner is responsible for reviewing, requesting, and maintaining accurate records of claim refunds using various software tools. They also coordinate with multiple departments to investigate overpayments, reconcile bank transactions, and prepare financial reports.
The Claims Examiner III is responsible for the accurate adjudication and processing of complex Medi-Cal managed care claims while serving as a subject matter expert. This role involves identifying processing issues, performing root cause analysis, and ensuring adherence to state and federal regulatory standards.
