Healthcare Authorization Specialist II - UM Data & Admin

Select how often (in days) to receive an alert: Job Category: Clinical Location: Los Angeles, CA, US, 90017 Position Type: Full Time Requisition ID: 13288 Salary Range: $47,840.00(Min.) -$57,062.00(Mid.) -$68,474.00(Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Authorization Technician II supports the Utilization Management (UM) Specialist by handling all administrative and technical functions of the authorization process including intake, logging, tracking and status follow-up. The Authorization Technician II collects information required by clinical staff to render decisions, assists the Manager and Director of the Utilization Management department in meeting regulatory time lines by maintaining an accurate database inventory of referral authorizations, retrospective reviews, concurrent reviews and grievance/appeal requests, and prepares UM Activity and Weekly Compliance Reports. In addition, the position performs data entry and processing of referrals/authorizations in the system, authorizes request consistent with auto authorization criteria, maintains confidentiality when communicating member information, and assists with the communication of determinations by preparing template letters for members/ providers, with other duties as assigned. Duties Functional Elements: Technical Support to UM Specialist: Processing of time sensitive authorization and pre-certification requests to meet department timeframes and regulatory requirements; Computer Input: Accurately and completely processing referrals/authorizations and distribute a complete file to UM Specialist within 2 hours of receipt; identify duplicate requests using the claims and verify existing authorization. Independently identifying and appropriately returning to claims or member services any file that is a duplicate to one already processed in the system; appropriately documenting what information was used in making this determination within 4 hours of receipt. Appropriate identification and timely notification of time sensitive requests; appropriately identifying for the staff which you support, request that are priority based on date of receipt and established Turnaround Time criteria for compliance. Accurate filing/maintenance of confidential member information. Creating secure, complete, files. Interface with members, medical personnel and other internal and external agencies; ensure all comply with L.A. Care requirements such as submitting requested information in a timely manner and using the approved Authorization Request form with complete medical information i.e.: ICD 10 codes, CPT, HCPC codes. (35%) Assist in the preparation of communication for authorization determinations, including, but not limited to preparing template letters for members and providers (authorization approval, denial, deferral, modification and pay/education). (30%) Assist in the technical aspects of the retrospective review process for authorizations and Member or Provider Appeals, including, but not limited to computer data entry, logging, copying, preparing of template letters for communication of appeal determinations to members, providers and partners (appeal uphold or overturn) and filing: Set up GNA files for review, log and keep track all due dates for each file. Inform nurses of a new case received from Grievance and Appeals Specialist.; submit all Grievances and Appeals response letters to Grievances Specialist on daily basis. (20%) Support UM Committee and Audit activity via Department performance reporting. Assure the accuracy of reports concerning inventory and department proficiency in maintaining regulatory standards and time frames. (5%) Perform other duties as assigned. (10%) Education Required Education Preferred Experience Required: At least 6 months of health care experience. Experience working in a cross functional work environment. Preferred: Experience in Medi-Cal managed care. 1 year of experience in UM/Prior Authorization. Skills Required: Demonstrated proficiency in Medical Terminology required. Strong verbal and written office communication skills. Proficient with Microsoft Office Suite and Adobe PDF. and Excellent organizational, interpersonal and time management skills. Must be detail-oriented and an enthusiastic team player. Preferred: Knowledge of QNXT computer systems a plus. Knowledge of the UM patient referral process. Knowledge of member’s health plan eligibility. Knowledge of member’s benefits coverage. Knowledge of Health Plan regulations. Knowledge of HMO/UM functions. Knowledge of ICD-10/CPT coding. Proficient utilizing electronic medical records and documentation programs. Licenses/Certifications Required Licenses/Certifications Preferred Medical Coding Certification Required Training Physical Requirements Light Additional Information Required: Weekends and holidays hours may be required, as well as OT based on a business need. Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offersa wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Nearest Major Market: Los Angeles Job Segment: EMR, Data Entry, Claims, Medical Coding, Healthcare, Administrative, Insurance #J-18808-Ljbffr L.A. Care