This position is responsible for receiving and filling requests for
information from providers and members, processing prior
authorization requests, administering notification of medical
services, inpatient hospitalization requests, and processing
High School Diploma/GED required
Knowledge in medical terminology, ICD-9/CPT Coding preferred
1 - 3 years health care experience preferred
Demonstrates problem-solving skills
Strong computer/typing skills
Excellent oral and written communication skills
Excellent listening skills
Strong service orientation with professional and courteous
Flexible and adaptable to quick changing environment(s)
Ability to work as a team player in a professional environment
Prior Authorization experience preferred.
SKILLS / REQUIREMENTS
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Process requests for Prior Authorization
a) Treatment request
b) Inpatient hospitalization
c) Phone requests
Verify eligibility within the database system to members and
Code each diagnosis of service and procedures according to
Handle telephone requests timely and accurately.
Update plan resources.
Inform Provider Relations of non-contracted providers.
Analyze daily faxed requests to determine coverage and approval
utilizing criteria. Utilize nurses for medical reviews when
Understands and abides by all departmental policies and procedures
as well as the organizations Corporate Integrity Program.
Attends mandatory Corporate Integrity Program education sessions,
as required for this position, including the annual mandatory
Standards of Conduct Class.
Participates actively in ensuring that all state and federal rules
and regulations are followed as they apply to this position.
Abides by all applicable laws and regulations as mandated by state
and federal laws and prevents being excluded or sanctioned from any
state and/or federal programs as they pertain to healthcare.
MM decision making is based only on appropriateness of care and
service and existence of coverage.
We do not specifically reward practitioners or other individuals
for issuing denials of coverage of service or care.
Financial incentives for MM decision makers do not encourage
decisions that result in underutilization.