Care Review Processor I

Care Review Processor (Managed Care)

Schedule: Monday–Friday, 8:00 AM – 5:00 PM PST
Work Environment: 100% Remote (must reside in one of 15 preferred states)
Equipment Required: Dual monitors and docking station
Education: High School Diploma or GED required

The Prior Authorization Clerk supports the Care Access and Monitoring (CAM) team by performing clerical and data entry tasks for ***** members requiring hospitalization or utilization review. This role ensures all service authorization requests and member inquiries are processed efficiently, accurately, and in compliance with State and Federal standards to promote high-quality, cost-effective healthcare delivery.

• Receive and process faxes and load authorization shells in the system.

• Enter authorization requests and provider inquiries received via phone, mail, or fax.

• Verify member eligibility, benefits, and provider contracting status.

• Determine diagnosis, treatment requests, and assign appropriate billing codes (ICD-9/ICD-10 and/or CPT/HCPC).

• Verify coordination of benefits (COB) status and inpatient census, including admits and discharges.

• Perform required actions per protocol using the appropriate database.

• Contact physician offices to request missing or additional information as needed.

• Notify Care Access and Monitoring Nurses and Case Managers of hospital admissions or changes in member status.

• Ensure timely responses and compliance with ***** operational timeframes.

• Maintain confidentiality and adhere to HIPAA and ***** Standards of Conduct.

• Meet department productivity, quality, and attendance standards.

• Participate actively in CAM team meetings and interdepartmental collaborations to support continuity of care.

• High School Diploma or GED.

• 0–2 years of experience in a Utilization Review department within a Managed Care environment.

• Prior experience in hospital or healthcare clerical, audit, or billing roles.

• Proficiency in medical terminology and common healthcare abbreviations.

• Strong computer skills, including Microsoft Office and accurate data entry (minimum 40 WPM).

• Ability to work independently and as part of a team in a fast-paced environment.

• Demonstrated communication, analytical thinking, and problem-solving skills.

• High regard for confidential information and professional integrity.