Premium Management Representative

GENERAL DESCRIPTION: Calls medical offices to request, receive by fax, and register documents contained in the medical records of Classicare policyholders, as required and according to the different initiatives worked on in the unit. Refers documents received by the medical offices to the Risk Assessment unit, to complete the Comprehensive Health Risk Assessment (CHRA) and/or code services offered by providers to Classicare policyholders. In addition, makes calls to Classicare policyholders to impact special initiatives directed to HEDIS/STARS. ESSENTIAL FUNCTIONS:

Calls medical offices to request the faxing of documents contained in the medical records of Classicare policyholders, as required and according to the different initiatives worked on in the unit, such as CHRA, Alternate Data Source (ADS), correction of data rejected by the Risk Adjustment Processing System (RAPS), MRP, FCodes, and ESRD, among others. Calls Classicare policyholders to impact special initiatives targeting Healthcare Effectiveness Data and Information Set (HEDIS)/STARS. Discusses with the physician the clinical referral generated by the evaluators and/or technicians.

Guides them to clarify any questions regarding the referral so that the provider can submit the appropriate correction, as requested. Attaches to the referral application the documents that are sent by the medical offices. Coordinates with the IPA/PCP unit the medical offices to be visited to pick up documents that were not received via fax, according to availability. Refers to the unit the medical documents received, to complete the CHRA and/or code the services offered toClassicare policyholders.

Informs the management of the steps taken and related to the status of calls made to medical offices, reception and registration of documents contained in the medical files of Classicare policyholders, and referrals submitted to different departments of the company to validate information, if applicable. Identifies and notifies the management of any situation referred by a provider, that cannot be completed within their responsibilities, as well as any situation that may imply a risk to compliance with established procedures.

Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices. May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document. MINIMUM QUALIFICATIONS: Education and Experience: Sixty (60) college credits equivalent to two (2) years of study or an Associate’s Degree. At least one (1) year of experience in customer service-related work. OREducation and Experience: High school diploma. At least two (2) years of experience in customer service-related work.

“Proven experience may be replaced by previously established requirements. ”Certifications / Licenses: Certification in billing processes and clinical coding in ICD-9-CM, and/or other health-related certifications is preferred. Other: Knowledge of the following subjects is preferred: Medical terminology (Basic), Essential elements of Clinical Documentation, RAPS errors, Clinical terms expressing a cause-and-effect relationship, Knowledge of the Risk Adjustment Model, and Automated Operational Call System (Aspect). Languages:

Spanish – Intermediate (comprehensive, writing and verbal)English – Intermediate (comprehensive, writing and verbal)“Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento”