Job Profile Summary
Responsible for screening and processing prior authorization requests in the medical care management program, including a broad range of requests for inpatient, outpatient and ancillary services. Adheres to policies and procedures in order to comply with performance and compliance standards and to ensure cost effective and appropriate healthcare delivery. Authorizes certain specified services, under the supervision of the manager, according to departmental guidelines. Per standard workflows and job aids per service type, forwards specified requests to the clinician for review and processing. Answers inbound phone calls from providers and other departments and redirects, as needed.
Job Description
Key Functions/Responsibilities:
• Prioritizes incoming Prior Authorization requests received from faxes and the provider portal.
• Processes incoming requests, including authorizing specified services, as outlined in departmental policies, procedures, and workflow guidelines. Requests clinical information, outreaches to providers for missing information.
• Refers authorization requests that require clinical judgment to Prior Authorization Clinician, Supervisor, or Medical Director.
• Meets or exceeds position quality, quantity, and data metrics and turnaround timeframes.
• Supports Prior Authorization Clinicians.
• Answers ACD line calls, verifies member eligibility and enters information necessary to document the caller’s request in Jiva. Triages calls and forwards to appropriate departments.
• Identifies and informs callers of network providers, services, and available member benefits. Maintains thorough understanding of services requiring authorization through use of the Plan’s CPT code look up tool and policies.
• Engages in professional communications, following department protocols for opening and closing the call and leaving messages.
• Informs provider of decision per department procedure.
• Coordinates resolution of escalated member or provider inquiries as related to Prior Authorization.
• Works with providers and key departments to promote an understanding of Prior Authorization requirements and processes.
• Maintains general understanding of applicable sections of member handbooks, evidence of coverage, Health Trio functionality, and WellSense website.
• Participates in team operational activities, including but not limited to handling primary responsibilities for triage function and department voicemail coverage.
• Meets organizational standards for assuring member and provider communications are accurately sent to appropriate recipients.
• Other duties as assigned.
Supervision Exercised:
o None
Supervision Received:
o General supervision is received.
Qualifications:
Education Required:
o Associate’s degree in healthcare, Social work or related area, or the equivalent combination of training and experience is required.
Education Preferred:
o Bachelor’s Degree.
Experience Preferred/Desirable:
o Three or more years of experience in medical practice administrative position.
o Experience with Jiva, FACETS, or other healthcare databases.
o Experience with Health Plan Utilization and Customer Service.
Required Licensure, Certification or Conditions of Employment:
o Pre-employment ****
Competencies, Skills, and Attributes:
o Ability to prioritize and manage multiple tasks in fast-paced environment within turnaround timeframes.
o Ability to process high volume of requests and meet performance targets with a 95% or greater accuracy rate***
o Sense of urgency.
o Strong customer service skills.
o Effective collaboration skills that work well in a team setting.
o Strong listening, oral and written communication skills.
o A strong working knowledge of Microsoft Office products.
Working Conditions and Physical Effort:
o Work is performed fully remotely.
o No or very limited physical effort required. No or very limited exposure to physical risk.
o Regular and reliable attendance is an essential function of the position.
