Prior Authorization Specialist

Summary:

• Responsible for screening and processing prior authorization requests in the medical care management program.
• Adheres to policies and procedures to comply with performance and compliance standards and ensure cost-effective and appropriate healthcare delivery.
• Work Mode: Remote

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 and 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.
• Identifies and informs callers of network providers, services, and available member benefits.
• 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.
• Participates in team operational activities, including 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.

Requirements:

• Associate’s degree in healthcare, social work, or related area, or the equivalent combination of training and experience is required.
• Ability to prioritize and manage multiple tasks in a fast-paced environment within turnaround timeframes.
• Ability to process a high volume of requests and meet performance targets with a 95% or greater accuracy rate.
• Sense of urgency.
• Strong customer service skills.
• Effective collaboration skills that work well in a team setting.
• Strong listening, oral, and written communication skills.
• A strong working knowledge of Microsoft Office products.

Preferred Skills:

• Bachelor’s Degree.
• Three or more years of experience in a medical practice administrative position.
• Experience with Jiva, FACETS, or other healthcare databases.
• Experience with Health Plan Utilization and Customer Service.