BusinessOperations - Authorization Specialist I - Authorization Specialist I

Prior Authorization Support

Position Purpose: Supports the prior authorization request to ensure all authorization requests are addressed properly and in the contractual timeline. Aids utilization management team to document authorization requests and obtain accurate and timely documentation for services related to the members healthcare eligibility and access.

Education/Experience: Requires a High School diploma or GED. Entry-level position typically requiring little or no previous experience. Understanding of medical terminology and insurance preferred.

Responsibilities: Supports and performs data entry to maintain and update authorization requests into utilization management system. Assists utilization management team with ongoing tracking and appropriate documentation on authorizations and referrals in accordance with policies and guidelines. Contributes to the authorization review process by documenting necessary medical information such as history, diagnosis, and prognosis based on the referral to the clinical reviewer for determination. Remains up-to-date on healthcare, authorization processes, policies and procedures. Performs other duties as assigned. Complies with all policies and standards.

Story Behind the Need Business Group & Key Projects: This request is to replace temp Jade Halloway-Gipson. Need additional temp to manage workload. May support in community support.

Typical Day in the Role: Will need to review documents received via fax and extract information needed to build authorization. Occasionally doing out reach to provider to obtain clarification of request or missing information. Required to send out notification of determination and adhere to strict deadlines. Will need ability to have good communication skill both verbal and written as letter will need to be created for providers per Medical guidelines.

Candidate Requirements: Education/Certification - Required: High School diploma. Licensure - Required: None. Years of experience required: None. Best vs. average: Performance indicators: Maintain quality of 95% or better. Maintain production of 95% or better.