This position is responsible for providing assistance with the resolution of authorization and/or claim issues in various work queues resulting from and calls taken from facilities and providers. Acts as liaison between providers, internal departments and specific accounts, clients, and claims department.
Resolves cases in queue due to member eligibility issues, referring provider verification or request, imaging provider verification, redirection, and retro reviews.
Assists with authorization problem resolution through research and facilitating the resolution of the problem in a timely fashion.
Process, forward, trend, and maintain records of authorization issues.
Acts as a troubleshooter to resolve problems among internal departments.
Handles special requests from Customers requiring manual workarounds or specials projects.
Investigates written/verbal complaints involving authorizations, and resolves complex issues with Customers and Providers.
Assists specific accounts who have special processes.
Observes and tracks authorization problem trends and works with internal department for resolution.
Assists with User Acceptance Testing (UAT).
Provides phone back-up coverage for other teams as needed.
Other Job Requirements
Responsibilities
Ability to review and interpret multiple contract/account information to successfully resolve issues regarding benefit plan administration; experience with account benefit structures.
Demonstrated ability for problem solving, meeting deadlines, initiative and follow-through.
Excellent written and verbal communication skills.
Knowledge of pharmacy benefits management.
Understanding of customer service performance metrics (ASA, abandonment rate, talk time).
General Job Information
Title
Customer Resolution Associate
Grade
18
Work Experience - Required
Claims, Customer Service
Work Experience - Preferred
Education - Required
GED, High School
Education - Preferred
Bachelors
License and Certifications - Required
License and Certifications - Preferred
Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
