Post Date: 09/09/2020
Close Date: 10/09/2020
The purpose of this position is to provide technical and clerical support for the DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) and home care services unit functions within the department. These functions involve processing authorization requests for DMEPOS and home care services from vendors, home health agencies and infusion providers. The Durable Medical Equipment Specialist (DMES) may not routinely perform all the essential functions on a daily basis. However, the expectation is that the DMES will have basic knowledge and skills to perform all the tasks needed in their role.
Essential Position Functions
- Verify member eligibility and determine primary insurer.
- Verify network providers and for non-network, determine if provider is loaded into QNXT.
- Verify codes, benefits, including benefit limits by primary insurer (Medicare) and if not funded, by secondary insurer (OHP).
- Obtain additional information, as needed, from requestor or other providers.
- Process authorizations according to member’s primary insurance, or secondary if not funded under primary according to:
- Authorization Guidelines
- NO AUTH List
- Levels of Review
- Desktop procedures
- Policies and procedures
- Document information received/obtained and action taken according to department’s documentation Standards.
- Identify pharmacy authorization requests, determine authorization requirements per website information, and if authorization is needed, forward to Pharmacy Unit for processing per established workflow process.
- Notify vendor/agency of the authorization decisions (no authorization required, approved, denied, or partial approval/partial denial).
- For denials, create denial letters and process according to established protocols; or for RN created denial letters, process according to established protocols.
- Process retroactive authorization requests and for approvals, determine if claim submitted and denied, and if so, notify claims department to reprocess and pay denied claims.
- For all processes, monitor timelines to ensure processing requests are completed within established timelines; urgent or standard requests.
- Identify members with care coordination needs and forward relevant information to the appropriate staff.
- Act as a resource to both internal/external customers regarding access to appropriate DMEPOS and HH services.