Care Review Processor I

Location: Fully Remote (Must be able to work Pacific Time hours)
Schedule: Monday Friday | 8:30 AM 5:30 PM PST
Assignment Length: 6 months with potential for extension or conversion

The Care Review Processor supports the Care Access and Monitoring (CAM) team by providing clerical, data entry, and coordination support for members requiring hospitalization or utilization review services. This role assists with authorization processing, provider communication, and triaging requests to the appropriate healthcare services staff to ensure timely, high-quality, and cost-effective care delivery in accordance with state and federal regulations.

• Answer incoming calls through a provider phone queue and respond to provider inquiries

• Send provider requests and authorization inquiries to nursing staff for review

• Coordinate and schedule Peer-to-Peer review requests between providers and medical staff

• Enter authorization requests and provider inquiries received via phone, fax, or mail into internal systems

• Verify member eligibility and benefits

• Determine provider contracting status and request appropriateness

• Document diagnosis and treatment requests

• Assign and verify billing codes (ICD-9, ICD-10, CPT, HCPC)

• Verify inpatient admissions and discharges and confirm hospital census updates

• Follow established protocols and update the appropriate authorization and utilization databases

• Contact physician offices to obtain missing documentation or additional information

• Notify CAM nurses and case managers of hospital admissions or member status changes

• Maintain accurate records while meeting department productivity and quality standards

• Ensure compliance with HIPAA confidentiality and data security requirements

• Provide excellent customer service to internal teams and external provider partners

• High School Diploma or GED

• 02 years of experience in utilization review, managed care, or healthcare administration

• Previous hospital, healthcare clerical, audit, or billing experience preferred

• Familiarity with medical terminology

• Experience working in a phone queue or high-volume call environment

• Ability to work independently in a remote environment

• Proficiency with Microsoft Office (Word, Excel, Outlook)

• Accurate data entry skills with a minimum of 40 WPM

• Strong communication and interpersonal skills

• Ability to problem solve and think analytically

• Ability to work effectively in a fast-paced environment

• Strong attention to detail and confidentiality awareness

• Ability to collaborate with cross-functional healthcare teams