Care Management Associate I (Appeals)
Company: MetroPlusHealth
Location: New York
Posted on: February 1, 2025
Job Description:
Empower. Unite. Care.MetroPlusHealth is committed to empowering
New Yorkers by uniting communities through care. We believe that
Health care is a right, not a privilege. If you have compassion and
a collaborative spirit, work with us. You can come to work being
proud of what you do every day.About NYC Health +
HospitalsMetroPlusHealth 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.Position OverviewThe Care Management
Associate I (CMA), under the direction of the Vice President of
Clinical Services, is responsible for the daily activities of
member case intake, processing functions, and associated workflow,
as well as for performing other duties associated with the
coordination of member care as outlined and/or assigned by their
manager.Job Description
Receive service requests from
providers and members via facsimile, provider portal, phone, and
mailReceive 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 benefitsStrive to provide
first-call resolution to all callersProvide superior customer
service to all providers and membersVerify 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 servicesReceive and process inbound correspondence to
ensure it is associated with the correct member and contains
adequate information for clinical reviewRefer to RN or MD as
indicatedGenerate denial letters which relate to the member's
ineligibility for services when appropriateFollow guidelines for
services which can be approved by the CMA under the direction of
the Medical DirectorGenerate 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 codesWork efficiently and diligently and
meet minimal required performance expectations and quality
requirementsAssist 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.Minimum Qualifications
High School diploma or GED (General
Equivalency Diploma)1 to 3 years of experience in an administrative
support role in either Utilization Management or
AppealsUnderstanding of medical terminology including ICD-10 and
CPT-4 codes preferredCall center or Customer Service experience
preferredProfessional Competencies
Integrity and TrustCustomer
FocusFunctional/Technical SkillsWritten/Oral CommunicationsStrong
work ethicEfficiency and attention to detailAbility to research on
the InternetAbility to communicate in English clearlyProficiency in
using a computer#LI-REMOTE#mph50
Keywords: MetroPlusHealth, East Orange , Care Management Associate I (Appeals), Executive , New York, New Jersey
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