New

Care Review Processor I (71639)

Professional Management Enterprises
United States, California, Los Angeles
Jun 05, 2025
Care Review Processor Ito work within the Care Access and Monitoring (CAM) team to provide clerical and data entry support for members that require hospitalization and/or utilization review for other healthcare services.Fully Remote* Must work PST Time Zone. The work schedule is Mon-Fri 8:00am-5:00pm PST. Essential Functions: Familiar withMedi-Cal Checks eligibility and verifies benefits, obtains and enters data into systems, processes requests, and triages members and information to the appropriate Healthcare Services staff. Respond to requests for authorization of services submitted to CAM via phone, fax and mail. Verify member eligibility and benefits. Determine provider contracting status and appropriateness. Determine diagnosis and treatment request. Assign billing codes (ICD-9/ICD-10 and/or CPT/HCPC codes). Determine COB status. Verify inpatient hospital census-admits and discharges. Perform action required by protocol using the appropriate database. Participates in interdepartmental integration and collaboration to enhance the continuity of care for members including Behavioral Health and Long-Term Care. Contact physician offices according to department guidelines to request missing information from authorization requests or for additional information as requested by the Medical Director. Required Education: High School Diploma/GED Required Experience:** 2-4 years of experience in a Utilization Review Department in a Managed Care Environment. Previous Hospital or Healthcare clerical, audit or billing experience. Experience with Medical Terminology.