Operations Senior Representative - Evernorth

The Operations Senior Representative acts as Subject Matter Expert (SME) in collaborating with Medical Directors, Post-Acute Care, Clinical Care Coordinators, Post-Acute Care facilities, Provider Engagement, Client Services, and various leadership members related to Post-Acute Care (PAC) medical utilization assignments including the monitoring of compliance trends during secondary reviews.

Analyzes operating Organization Determinations, Appeals, and Grievances (ODAG) reports, updates and processes findings to ensure business service level agreements and regulatory turnaround times are met.

Adheres to Centers for Medicare and Medicaid Services regarding state contractual policies and procedure requirements.

Collaborates with nurses to ensure efficient delivery of regulatory managed care notification letters to Servicing Providers and members, monitors and processes provider requests related to Medical Director Recommendations delivering adverse determinations, and facilitates direction to providers for first level of appeal requests.

Demonstrates understanding of the Initial and Concurrent Review processes and assists the PAC training team with Medical Director unable to approve processes as well as mentoring Field Care Coordinators and Servicing Providers with Medical Director concurrent extensions.

Ideal candidate will have a combination of:


* High School Diploma or GED


* Medical Assistant or Medical Technician Licenses, preferred


* One year of Call Center experience, preferred


* Two years of healthcare call center experience strongly preferred


* Experience with PAC Manager & eP applications a plus


* Must be able to work schedule to cover operating hours between 7am - 7pm Central Standard Time.


* Maintain flexibility to variations in work volume/work schedule, which sometimes require extended working hours.

Occasional weekend/after-hours coverage may be required.

Duties and Responsibilities


* Identify and report to Supervisor inefficiencies with processes


* Research and compile information for complex cases and client provider complaints


* Execution of frontline telephonic queue monitoring and operating translation portal


* Record accurate documentation from clinical team collaborations including scheduling of post determination conversations, Medical Director rounds, and requesting clinical data for completion of conditional Medical Director recommendation reviews.


* Triage referrals


* Satisfy clinical requests from PAC Team related to Medical Director recommendations


* Execution of expedited referral requests after Medical Director final determination


* Create new services requests from clients


* Other duties as assigned

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

For this position, ...