HEDIS Coordinator

HEDIS, a tool used by more than 90 percent of America’s health plans, measures performance on important ranges of care and service. HEDIS coordinators perform different tasks to ensure HEDIS data and reports are accurate, including investigation, auditing, and improvement opportunities.

Job Duties and Responsibilities

  • Coordinate, complete, and update management on all HEDIS processes and results
  • Organize and maintain a plan of action to improve HEDIS scores
  • Request and evaluate reports for member compliance and improvement opportunities for each HEDIS measure
  • Work with providers and internal departments on rate investigation and validation activities, which includes maintaining all evidence, documentation, and changes
  • Oversee the HEDIS project for quality and timeliness regarding nurse assignments, vendor oversight, and timeline adherence
  • Ensure compliance by conducting quality audits and maintaining all data and process controls

Education and Qualifications

  • Bachelor’s degree in related field or equivalent experience
  • 3+ years of quality improvement or healthcare related experience
  • HEDIS requirements preferred
  • Must be organized with the ability to keep accurate notes and records
  • Excellent verbal/written communication skills
  • Proficient in Microsoft Word, Excel, and Outlook
  • Should possess leadership capabilities

Referral Specialist

Referral specialists generally work in an office setting and are responsible for making sure patients are approved by their insurance company to see a specialist. They also handle pre-authorization for specific procedures and gather financial information on patients, ensuring they are aware of costs and have a plan for payment set in place.

Job Duties and Responsibilities

  • Schedule appointments, surgeries, and medical consultations
  • Maintain referral records and data reports
  • Prepare patients medical records before their visit
  • Communicate with insurance companies
  • Manage follow-up appointments

Education and Qualifications

  • HS Diploma
  • Associates degree or higher
  • 1+ years of medical office experience
  • Must be very organized and detail oriented
  • Needs to be able to work under pressure
  • Excellent written and oral communication skills
  • Basic knowledge of email and computer programs
  • Should be familiar with medical terminology

Usually, referral specialists work full-time, but hours can vary depending on the employer. Because much of the work is done using a computer and telephone, this is mostly a sedentary position.

Prior Authorization Nurse

The prior authorization nurse is responsible for administering prospective reviews of authorization requests, which may include treatments, services, admissions, home care, and referrals. The nurses will also assist in preparing documentation, performing audits of patient records, and helping management with tasks as needed.

Job Duties and Responsibilities

  • Provides clear documentation for approving requests
  • Coordinate care and services for members
  • Update clinical information utilizing various medical management systems
  • Handles telephone requests in a timely and accurate manner
  • Help with interdepartmental projects as needed
  • Develop and update health plan resources and forms
  • Provide training to prior authorization technicians

Education and Qualifications

  • RN/LPN
  • 2+ years clinical nursing experience in an intense care setting
  • Experience with prior authorizations
  • Basic knowledge of computers and working with software programs
  • Excellent verbal and written skills
  • Must be organized
  • Should be a team player and have a great attitude
  • Strong service orientation and professionalism

Medical Technologist

Medical technologists are licensed healthcare professionals who work in hospitals or independent labs, and use sophisticated procedures and equipment to perform tests on blood and bodily fluids. The samples are then analyzed for chemical content, cell count, drug levels, blood type, and any microorganisms like bacteria or parasites.

Job Duties and Responsibilities

  • Prepare samples for examination
  • Use automated equipment and specialized instrumentation
  • Perform numerous tests simultaneously
  • Interpret results accurately
  • Deliver test results to physicians, researchers, or patients
  • Cross-match blood for transfusions

Education and Qualifications

  • HS Diploma or GED
  • Bachelor’s Degree
  • Licensure and certification vary by state
  • Professional certification preferred
  • Must have excellent communication skills and be detail-oriented
  • Need to have the ability to use sophisticated medical equipment
  • Have a flexible schedule with the ability to be on call
  • Must be able to handle standing for long periods of time

Laboratory Assistant

Laboratory assistants work in medical laboratory settings, such as a physician’s office, research lab, clinic, or hospital under the supervision of a physician or lab personnel to collect, prepare, and assist with the examination of specimens. Many individuals accept this entry-level position to gain experience to become laboratory technicians in the future.

Job Duties and Responsibilities

  • Prepare slides or cultures
  • Collect specimens
  • Assist with tests or experiments
  • Ensure lab complies with all laws and regulations
  • Control infections
  • Record results and maintain logs
  • Prepare various types of laboratory equipment for use
  • Clean and organize lab
  • Operate microscopes, machinery, meters, filters, pumps, etc.

Education and Qualifications

  • HS Diploma or GED
  • Phlebotomy experience
  • Strong attention to detail
  • Must be organized
  • Should be able to understand measurements and basic mathematical calculations
  • Computer skills are critical
  • Can follow verbal and written instructions

Specimen Processor

The laboratory specimen processor is responsible for a variety of tasks, which include specimen receiving and sorting, lab support, and test data entry. This position requires a considerable amount of flexibility, attention to detail, and accuracy.

Job Duties and Responsibilities  

  • Receive and open specimen bags
  • Enter inventory, patient demographics, and test codes into computer system
  • Prepare specimens for laboratory testing and analysis
  • Ensure specimens and requisitions are correctly labeled
  • Validate requisitions against specimens before scanning into the system
  • Will be responsible for cross-contamination potentials
  • Must clean and maintain laboratory and all equipment

Education and Qualifications

  • HS Diploma, GED, or 1+ years of similar work experience
  • Must possess excellent organizational skills, attention to detail, and PC experience
  • Previous laboratory experience is a plus
  • Should be able to work independently and in a team
  • Needs to be able to handle working in a fast pace, repetitive environment
  • Have a flexible schedule to accommodate business needs
  • Must be dependable and punctual

Enrollment Rep

The enrollment representative serves as a liaison between the company and its members and providers. You will be expected to respond to and resolve questions and issues from current and prospective members or their representatives, providers, and other relevant parties.

Job Duties and Responsibilities

  • Responds to member and provider inquiries by phone, email, or walk-in
  • Demonstrates appropriate soft-skills including empathy, active listening, courtesy, politeness, helpfulness, etc.
  • Records, investigates, and resolves member complaints
  • Educates new members and re-educates existing members regarding health plan procedures
  • Logs, tracks, and documents all issues in accordance with all applicable guidelines
  • Demonstrates skills necessary to perform exceptional customer experience
  • Works error and exception reports in a timely manner
  • Processes and creates eligibility lists and reports

Education and Qualifications   

  • HS diploma or GED
  • 6+ months of healthcare call center or customer service experience
  • Strong background in enrollment/eligibility
  • Knowledge of claims processing
  • Strong ability to multitask
  • Good telephone skills
  • Knowledge of Microsoft programs

As an enrollment representative, you will work to ensure members receive a level of service that goes beyond their expectations.

Health Coach

As a health coach, you are responsible for guiding members through any diet and lifestyle changes. You will provide patients with the necessary tools needed to meet their preventative, chronic, and acute care needs by engaging and encouraging them to take responsibility for their health through the adoption of lifelong healthy behaviors.

Job Duties and Responsibilities

  • Acts as a health coach for patients
  • Meets minimum standards for productivity and clinical results
  • Provides assessments of new participants for determining clinical risk
  • Maintains accurate and timely documentation in member management software
  • Acts as a case manager when integrating with other health care service vendors
  • Completes required reports in a timely manner
  • Enhances clinical and counseling knowledge by attending training sessions
  • Handles confidential forms appropriately

Education and Qualifications

  • HS diploma or GED
  • Must be a Registered Dietician
  • Must possess excellent phone, written, and computer skills
  • Experience in a service environment is a plus
  • Needs to be compassionate, kind, and open-minded

Health coaches have an especially impactful role by assisting in ongoing care, which can enhance patient experiences and improve outcomes overall.

Grievance and Appeals Rep

The grievance and appeals representative is responsible for reviewing, analyzing, and processing policies associated to claim events to establish what the company’s liability and entitlement will be. Grievances are complaints made regarding providers or how a benefit decision was determined.

Job Duties and Responsibilities

  • Research complaints (grievances) and log and track the information as it moves through the clinical process or is tasked through internal contacts
  • Contact customers to collect information and communicate disposition of the case, document all interactions
  • Review cases to determine if it needs further review by a clinician
  • Use sound, fact-based decision-making skills to render a decision for non-clinical complaints
  • Use appropriate templates to complete necessary documentation for final appeals or grievance determination
  • Relay appeal or grievance information to members, providers, and internal/external parties within the appropriate timeframe
  • Create weekly statistical reports and prepares appeal hearings

Education and Qualifications

  • HS diploma or GED
  • 1+ year of work experience in a similar environment
  • Strong written communication skills, especially with grammar and spelling
  • Attention to detail and accuracy
  • Strong computer skills, must be able to run reports and manipulate/track/log data
  • Knowledge of Microsoft programs and CMS Guidelines
  • Experience with healthcare, medical, or pharmacy terminology is preferred

To be successful in the appeals and grievance representative role, you’ll need to possess strong analytical skills and effectively interact with other departments to attain original claims processing details.

AR Rep

Accounts receivable representatives provide financial, clerical, and administrative services to ensure efficient, timely, and accurate payment of accounts.

Job Duties and Responsibilities

  • Collect on refunding/crediting balances, workers compensation, corporate billing accounts, self-pay, travel health insurance claims, and insurance collections
  • Collect on drug screens and pre-employment physicals for corporate accounts
  • Accurately and thoroughly document the relevant collection activity performed
  • Perform appropriate billing functions, including manual re-bills as well as electronic submission to payers
  • Manage and maintain desk inventory, complete reports, and resolve high priority and aged inventory
  • Inform management of any issues such as payer, system, or escalated account.
  • Respond promptly to telephone messages and emails as needed

Education and Qualifications

  • High school diploma or GED equivalent
  • (6) months- 1+ years of healthcare insurance collections
  • 2+ years of medical AR/collections and billing experience
  • Experience with processing refunds and denials
  • Great data entry skills
  • Organized with great attention to detail

General math skills