The role involves reviewing and educating providers regarding disputes on adjudicated claims related to code editing denials or financial recovery. The coordinator also extracts clinical information from medical records to assign appropriate procedural terminology and medical codes like ICD-10-CM and CPT.

The Care Coordinator supports members by closing care gaps and addressing coordination needs under the direction of the RN Case Manager, handling tasks like referrals, authorizations, appointment setting, and documentation for members with complex chronic care needs. Responsibilities include telephonic outreach to members, creating documentation for discharges, managing alerts, and acting as a patient advocate within the Case Management team.

The specialist will be responsible for supporting the reimbursement process for cell and gene therapies, ensuring claims are accurately processed and reimbursed in a timely manner by verifying insurance coverage and managing appeals and denials. Key duties include collaborating with providers and insurance companies to resolve issues and maintaining detailed records of all reimbursement activities.

The Authorization Specialist is responsible for processing all authorization documentation according to regulations, ensuring accurate billing by meeting third-party payer deadlines and monitoring accounts for ongoing authorization needs. This role involves preparing and entering accurate data, timely follow-up on pending authorizations, and collaborating with insurance, collection, and clinical teams to resolve billing issues.