Now Hiring - Lumeris, Inc. - Medical Services Representative - Remote in Saint Louis, MO

Medical Services Representative - Remote Supports the Medical Management Department, which acts as a resource to all Lumeris clients and providers. Administers daily coverage requests for health care services including ambulance transport, inpatient hospitalization, skilled nursing care, home nursing services, durable medical equipment, and outpatient procedures/ pharmaceuticals. Supports clinical staff and performs administrative tasks as required by the Centers for Medicare and Medicaid Services (CMS).

• Receives preauthorization and referral requests via provider calls or faxes.
• Conducts initial benefit coverage and medical necessity clinical screening using Medicare and plan-defined guidelines in coordination with a pre-certification nurse.
• Documents referrals and authorizations into appropriate system (i.e., Facets) and provides confirmation of entry back to requesting provider.
• Documents inpatient notifications from facilities and reports them to plan and network provider case managers.
• Performs data entry to support the processing of Health Risk Appraisals (HRAs).
• Adheres to regulatory and departmental timeframes for review of requests received.
• Maintains HIPAA standards and ensures compliance for protected health information (PHI).
• Ensures compliance with all state and federal regulations and guidelines in daily activities.
• Performs special projects, as assigned.

• High School diploma, GED, or equivalent
• 1+ year of relevant experience or the knowledge, skills, or abilities to succeed in the role
• Experienced using Microsoft Office
• Good verbal and written communication skills
• Strong customer service skills
• Ability to work effectively within a team
• Ability to maintain a positive attitude and use proper phone etiquette
• Favorable judgement skills
• Strong organizational skills
• Ability to multi-task in a diverse and fast-paced environment

• Experience with Facets
• Previous Insurance/Pre-Service experience
• Previous managed care and call center experience
• Working knowledge of medical terminology

• While performing the duties of this job, the employee works in normal office working conditions.

• The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties and responsibilities.

$15.87-$19.47 No- Not Member Facing Position St. Louis, MO Full time