Job Overview: The Patient Service Rep provides clerical and data entry support for Molina Members requiring hospitalization or utilization review for healthcare services. This role ensures the delivery of high-quality, cost-effective healthcare services in compliance with State and Federal requirements. The Patient Service Rep is a key contributor to optimal member outcomes.

Essential Functions:

• Provide computer entries for authorization requests and provider inquiries received via phone, mail, or fax, including verifying member eligibility and benefits, determining provider contracting status, diagnosis and treatment requests, and assigning billing codes (ICD-9/ICD-10, CPT/HCPC).
• Determine COB status and verify inpatient hospital census, including admissions and discharges.
• Perform required actions using appropriate databases in accordance with established protocols.
• Respond to service authorization requests submitted to CAM through phone, fax, and mail within Molina’s operational timeframes.
• Collaborate interdepartmentally to enhance continuity of care, including working with Behavioral Health and Long Term Care teams.
• Contact physician offices per department guidelines to request missing information for authorization requests or additional data as needed.
• Provide excellent customer service to internal and external customers.
• Meet 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 member status changes.
• Maintain confidentiality and comply with HIPAA regulations.
• Participate actively in Care Access and Monitoring meetings and adhere to Molina’s attendance and workplace safety standards.

Knowledge, Skills, and Abilities:

• Strong communication, problem-solving, and interpersonal skills.
• Knowledge of medical terminology and abbreviations.
• Analytical thinking with the ability to solve problems effectively.
• High regard for confidentiality and the ability to work in a fast-paced environment.
• Proficiency in Microsoft Office and accurate data entry at a minimum of 40 WPM.
• Ability to work independently and as part of a team.

Required Education:

• High School Diploma or GED.

Required Experience:

• 2-4 years of experience in a Utilization Review Department in a Managed Care Environment.
• Previous experience in hospital or healthcare clerical roles, audits, or billing.
• Familiarity with medical terminology.