Care Review Processor I


Website Administrative

Reference Code: 4782

Position Title: Care Review Processor I, 
Location: REMOTE, Columbus, OH, 43215
Duration: 6 months with possible extension
Target start date: 3/1/2021


• Contractor will start remote until the offices open and then he/she will be expected to come into the office 5 days a week. The contractor will be required to come into the office fulltime Monday – Friday. All OT and regular hours will be worked in office, once the site opens up.
• Position located in Columbus, OH.
• Mandatory OT
• The team is a very strict production team. They have state mandated goals of building 40+ authorizations or sending 52 member letters, per day. Healthcare experience is nice, but not mandatory. Client is primarily looking for someone with very strong typing (45+wpm), data entry, and attention to detail skills. The authorizations and member letters need to be processed correctly and at an extremely fast pace. Microsoft office skills are a must. The contractor needs to have a dedicated workspace at home, free from distractions to ensure production goals are met and to ensure all PHI is protected at all times.
• The contractor will send member letters and/or build member authorizations. The contractor will work out of a queue in our PC system, Clinical Care Advance. The Manager assigns all the tasks the contractor will need to complete for the day, each morning. The contractor will be expected to work independently and process all the requests in their queue for the day. After the authorization is built, it is then uploaded into CCA and faxed to the provider rendering the services to our member. Every authorization and letter request is different, but the job is a very tedious and monotonous job. The team is also working mandatory OT of 5-10 hours a week. After the training period of 2 weeks-30 days (depending on how fast they pick up the process), the contractor will be expected to work the mandatory OT as well.



  • Works within the Care Access and Monitoring (CAM) team to provide clerical and data entry support for Members that require hospitalization and/or utilization review for other healthcare services.
  • Checks eligibility and verifies benefits, obtains and enters data into systems, processes requests, and triages members and information to the appropriate Health Care Services staff to ensure the delivery of high quality, cost-effective healthcare services according to State and Federal requirements to achieve optimal outcomes for Members.

Essential Functions:

  • Provide computer entries of authorization request/provider inquiries by phone, mail, or fax. Including: o Verify member eligibility and benefits,
  • Determine provider contracting status and appropriateness, o Determine diagnosis and treatment request
  • Assign billing codes (ICD-9/ICD-10 and/or CPT/HCPC codes), Determine COB status
  • Verify inpatient hospital census-admits and discharges
  • Perform action required per protocol using the appropriate Database.
  • Respond to requests for authorization of services submitted to CAM via phone, fax and mail according to operational timeframes.
  • Participates in interdepartmental integration and collaboration to enhance the continuity of care for members including Behavioral Health and Long Term Care.
  • Contact physician offices according to Department guidelines to request missing information from authorization requests or for additional information as requested by the Medical Director.
  • Provide excellent customer service for internal and external customers.
  • Meet department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores.
  • Notify Care Access and Monitoring Nurses and case managers of hospital admissions and changes in member status.
  • Meet productivity standards.
  • Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
  • Participate in Care Access and Monitoring meetings as an active member of the team.
  • Meet attendance guidelines per Healthcare policy.
  • Follow Standards of Conduct guidelines as described in Healthcare HR policy.
  • Comply with required workplace safety standards.


  • Demonstrated ability to communicate, problem solve, and work effectively with people. Working knowledge of medical terminology and abbreviations.
  • Ability to think analytically and to problem solve.
  • Good communication and interpersonal/team skills.
  • Must have a high regard for confidential information.
  • Ability to work in a fast-paced environment.
  • Able to work independently and as part of a team.
  • Computer skills and experienced user of Microsoft Office software.
  • Accurate data entry at 40 WPM minimum.


  • Required Education: High School Diploma/GED
  • Required Experience: 0-2 years of experience in a Utilization Review Department in a Managed Care Environment.
  • Previous Hospital or Healthcare clerical, audit, or billing experience. Experience with Medical Terminology.



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