The purpose of the position is responsible for accurately and timely completing the authorization process for identified health service requests for all managed care programs. Once an authorization request is received by fax or by the Call Center, the request must be reviewed by the position to verify member status, provider participation, correct benefit plan, benefit limitations, and benefit exclusions. The position is responsible for the authorization of health care services if appropriate based on information obtained or defers authorization to a higher level. This position participates in provider inquires, claim research, and problem resolution. On a weekly rotating basis this position assumes additional responsibilities as the Lead Intake Person and is responsible for prioritizing incoming authorization request, , STAT request received electronically, by fax or through the Intake Call Center. This position performs various administrative tasks in support of department functions assigned by the Manager of Authorization and may include ordering and receiving supplies. This position will be responsible on a rotating basis to be the Lead Intake Person and assume responsibility for prioritizing incoming authorization request to meet the 3 day (72 business hours) turnaround time.
Analyzes health service request for appropriateness and accuracy of information based on member eligibility status, provider eligibility status, diagnosis, type of request and benefit plan. Approves authorization request or denies request based on a technical denial. Identifies and escalates health care request that require clinical review.
On a rotating basis this position assumes the responsibilities as the Lead Intake Person and is responsible for prioritizing incoming authorization request.
Responsible for completing all urgent and stat requests received electronically, by fax or through the Call Center.
Apply benefit limitations and exclusions to health service request.
Analyze health service requests for appropriateness and accuracy of information.
Verify correct benefit plan based on eligibility.
Perform authorization research for missing information, existing authorization, authorization not required for service request and duplicate request prior to rendering services.
Responsible for communication and support to the C.L. Brumback Health Centers.
Research authorization issues and perform claim research as it pertains to an authorization requirement.
Verify provider participation and contracted provider status.
Prioritize health service request in order to meet the three day (72 business hours) turnaround standard.
Perform data entry of all required information pertaining to the authorization into the managed care software system.
Communicate with providers in an effective and professional manner.
Initiate problem resolution per provider’s request.
Maintain and update comprehensive knowledge of medical terminology.
Validate and select appropriate ICD-10, HCPC, CPT-4 codes for billing purposes.
Responsible for troubleshooting phone calls through the Call Center in a timely, professional and courteous manner as needed or escalating to the Manager of Authorization.
Maintain and update knowledge of Health Care District benefit plan.
Responsible for covering in the fax room as needed.
Ensure adherence of patient confidentiality and HIPAA compliance on all documentation and maintain secure recordkeeping.
Assist with various administrative tasks in support of department functions assigned by the Manager of Authorization and may include ordering and receiving supplies.
Emergency duty may be required of the incumbent that includes working in Red Cross shelters or to perform other emergency duties including, but not limited to, responses to threats or disasters, man-made or natural.
High school diploma or GED required.
Three (3) to five (5) years’ experience in a clinical setting such as a physician’s office, Utilization Department in health care or insurance company with knowledge of medical terminology, coding, billing and customer service.
Minimum of three (3) years’ experience in the authorization process and be able to key authorization request timely and accurately.