Clinical Documentation Specialist

Clinical Administrative Support Role

We are looking for a clinical administrative support role that will be responsible for receiving, registering, and forwarding requests for organizational determination and/or any associated clinical documentation or documentation for the clinical management of the insured. Works with the authorizations of services already predetermined through the automatic process using the benefits criteria and in compliance with the applicable organizational determination regulation and universes, reports, and the applicable regulation. If you have strong attention to detail skills and healthcare industry background this position is for you!

Essential Functions:

• Receives via facsimile, email, regular mail, or provider portal the requests for pre-service organizational determination and/or any clinical documentation for insured management.
• Performs Gatekeeper roles according to operational needs to support group leaders in classifying the documentation received and distributing the rest to the technicians.
• Check the expiration date of faxes in conjunction with the group leader.
• Manages and analyzes assertively and exhaustively the documentation received, including medical orders, to establish the type of service requested and the level of urgency and ensure that it meets the minimum requirements.
• Performs the eligibility search and the Pre-authorization requirement of the requested service. Validates information with the provider to complete the process.
• Documents the pre-authorization in the insured's file, entering the data that complies with the requirements established in reports and/or applicable regulations.
• Handles complex requests such as services in the US, durable medical equipment, and hospital discharge requiring additional interventions in direct communication with clinical areas to facilitate the process.
• Performs the authorization of services already predetermined through the automatic process using the benefits criterion in compliance with the applicable regulation, including notification to the insured/provider.
• Monitors assigned request times to maintain the compliance percentage for both authorizations and area assemblies.
• Answers the calls received in the unit in compliance with HIPAA regulations and forwards them to the corresponding programs, including calls with complex scenarios such as those in the US requiring intervention and even guidance and assistance.
• Appropriately handles appeals requests requiring communication and service alliances with the Grievances and Appeals Unit, knowledgeable about the appeal scenarios and the impact on STARS.
• Works with the queries and requests referred from the Call Center and Service Centers to facilitate the service either by modifying the Pre-authorizations or handling the verbal requests of the insured.
• Inform the Providers Department of the services that require payment agreement letters for the additional nonparticipating providers. Coordinates the configuration of non-existent providers in the tools.
• Complies fully and consistently with the Company's standards, policies, and procedures and the local and federal laws applicable to our industry, business, and employment practices.

Requirements:

Associate's Degree and/or sixty to sixty-four (60-64) university credits equivalent to six (6) months to one (1) year of studies in a health-related area.

At least one (1) year of related experience.

Other: Knowledge of Medical Terminology. CPT and ICD-10 Codes are preferred.

Languages:

Spanish Intermediate (conversational, writing, and comprehension)

English Intermediate (conversational, writing, and comprehension)

Required availability: Monday to Saturday, 8:00am - 6:00pm (rotating schedules) Hybrid Modality

Compensation: $13.25 ph + benefits

TPIS is an employer with equal opportunity in employment and take Affirmative Action to Recruit Women, Minorities, Protected Veterans, and Persons with Disabilities.