Intake Representative - ALBUQUERQUE, NM

About the role

In this remote Intake Representative role, you will work in a fully electronic environment, reviewing incoming requests for utilization review and other medical management services, verifying that documentation is complete and accurate, and ensuring cases are ready for clinical review.

Responsibilities

• Work in a fully electronic environment, reviewing incoming requests for utilization review and other medical management services, verifying that documentation is complete and accurate, and ensuring cases are ready for clinical review.
• Use an electronic medical record system and other platforms to validate eligibility, confirm claim and provider information, compare documentation across sources, and follow up as needed to gather missing details.
• Balance queue-based work with inbound calls, managing priorities independently throughout the day.
• Validate the request submitted via the Comagine Health Provider Portal for accuracy and completeness.
• Screens cases for required medical information based on type of request, determining if information is sufficient for clinical review.
• Obtain clinical information from the client systems when indicated or contact provider to obtain information required for review.
• Determine based on training when a scripted review is indicated based on contract requirements.
• Process requests after clinical reviewers, or managers to ensure language and determination information is complete before sending letters to providers.
• Respond to inbound telephone requests with clear documentation in the care management system of calls.
• Enter case information from original source documentation or validate information entered by providers in the portal.
• Make courtesy calls with case reference numbers.
• Provide notification of completed review and additional information needed, when applicable.
• Contribute to orientation and training of other non-clinical employees.
• Create templates for complex reviews, perform internal quality reviews, and/or participate in provider outreach activities.
• Perform scripted clinical reviews and refer reviews requiring further action to clinical review staff.
• Notify providers of decertification or potential denial of services by phone or in writing as required by contract.
• Complete case after review, returning to clinician or sending to client based on procedure.
• Arrange ancillary authorization requests such as transportation and accommodation.
• Obtain customer consent for care management services to be performed.
• Correspond with facilities, providers, and others.
• Cook up non-clinical functions and intervention, as directed.
• Perform supervised closure of cases upon completion of review by a clinical reviewer, as directed.

Requirements

• High school diploma or equivalent or equivalent combination of education and/or work experience in related field may be substituted.
• 2 years of related work experience or customer service experience.
• 1 year of work experience in healthcare.

Qualifications

• Intermediate understanding of medical terminology.
• Intermediate Microsoft Office Suite proficiency.
• Demonstrated proficiency with medical terminology.
• Participate in orientation and training of other Intake staff.

Skills

• Naturally curious.
• Able to work independently.
• Bring a high level of attention to detail and consistency in your work.

Benefits

• Medical, dental and vision insurance.
• Paid time off for vacation, illness and volunteering.
• Retail savings plan with employer contribution.
• Adoption financial assistance.
• Paid parental leave.
• And much more!

Pay

Compensation is commensurate with experience.

Schedule

The role involves frequent use of computers, phones, and virtual communication tools. Employees must be able to sit for extended periods, communicate effectively. Some positions may require operating a motor vehicle for business purposes; in such cases, employees must maintain a valid driver’s license and meet the organization’s driving eligibility requirements.

Physical Requirements & Work Environment

This position is primarily remote and performed in a home-based setting, requiring reliable internet access and a workspace free from significant distractions. The role involves frequent use of computers, phones, and virtual communication tools. Employees must be able to sit for extended periods, communicate effectively. Some positions may require operating a motor vehicle for business purposes; in such cases, employees must maintain a valid driver’s license and meet the organization’s driving eligibility requirements. Reasonable accommodations will be provided to enable individuals with disabilities to perform essential functions.