Care Review Processor

About the Role

We are looking to hire several Care Review Processors to join our Care Access and Monitoring (CAM) team remotely. This role involves evaluating and handling inpatient and prior authorization requests, verifying member eligibility and benefits, maintaining authorization documentation, and ensuring requests are routed for appropriate clinical review. This position requires accuracy, attention to detail, and adherence to compliance standards in a dynamic environment.

Key Duties

• Process inpatient and prior authorization requests received through various channels including phone, fax, mail, and electronic systems.
• Accurately enter and update authorization records in internal systems.
• Verify member eligibility, benefits, and coordination of benefits (COB) details.
• Review authorization submissions for completeness and request any missing information from healthcare providers.
• Assess provider network status and determine appropriateness of requests.
• Assign relevant diagnosis and procedure codes such as ICD-9, ICD-10, CPT, and HCPCS.
• Confirm hospital admission, discharge, and inpatient census data.
• Forward cases requiring medical necessity review to clinical staff or Medical Directors.
• Keep detailed, accurate documentation of all case activities.
• Manage workload efficiently to meet productivity, quality, and turnaround metrics.
• Deliver exemplary customer service by responding to provider inquiries.
• Collaborate with interdisciplinary teams including nurses, case managers, Behavioral Health, and Long-Term Care to promote care continuity.
• Ensure compliance with HIPAA and federal, state, and organizational regulations.

Qualifications

• High school diploma or GED is required.
• Experience in processing and loading authorization requests.
• Proficient data entry skills and comfort with computer systems.
• Familiarity with Microsoft Office suite.
• Knowledge of medical terminology and abbreviations.
• Ability to handle confidential information professionally.
• Strong communication, organizational, and problem-solving abilities.
• Capacity to work independently and as part of a team.
• A minimum typing speed of 40 words per minute.

Preferred Experience: Prior experience in Utilization Management or Utilization Review, Managed Care, healthcare administration, hospital clerical work, medical billing, audits, authorizations, or prior authorizations and benefits verification. Knowledge of ICD-9, ICD-10, CPT, and HCPCS codes is advantageous.

Requirements for the Position

• Must have a dedicated workspace at home and reliable internet connectivity.
• Need for dual monitor setup with docking station preferred, or at least a single monitor with appropriate connections.
• Capability to fully support remote work requirements.
• Will access Protected Health Information (PHI); experience with Medicaid business line is relevant.

Schedule and Location

• Role is fully remote and open to candidates residing in Arizona, Washington, Utah, Texas, New Mexico, Idaho, and Iowa states.
• Available schedules include one opening Tuesday through Saturday from 9:00 AM to 6:00 PM PST, and four openings Monday through Friday from 9:00 AM to 6:00 PM PST.
• The initial contract is for six months with an unknown possibility for extension.

Ideal Candidate

The ideal hire will have experience working in fast-paced healthcare settings involving authorizations, utilization management, and healthcare operations. A commitment to quality support of members and providers is essential.