Prior Authorization Specialist

Job Title

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.