Authorization Specialist

Join The Team At Chorus Community Health Plans

Are you ready to make a difference? Do you believe in the power of health insurance to change lives? At Chorus Community Health Plans, we don't just offer jobs, we offer opportunities to be part of something bigger, something that matters. By joining our team, you'll become a vital force in improving access to healthcare, promoting health equity and strengthening communities. Join us in our mission to make quality healthcare accessible to all.

Chorus Community Health Plans (CCHP) is not just another health insurance company; we are a community committed to transforming lives. Founded in 2005, CCHP is a trusted health maintenance organization (HMO) based in Wisconsin. We are a part of Children's Wisconsin, one of the state's most respected healthcare organizations. At CCHP, our core values - Purpose, Collaboration, Health, Innovation, and Integrity - drive us to provide exceptional service to the individuals, children, and families we serve.

Our programs:

• BadgerCare Plus: CCHP, the second largest BadgerCare health plan in Wisconsin serves over 130,000 adults and children in 27 counties in eastern Wisconsin.
• Care4Kids: We're the pioneers of Wisconsin's Foster Care Medical Home initiative, providing vital health care coordination services to 2,800 children in out-of-home care in Southeastern Wisconsin. Through our "medical home" model, we strengthen care quality, access, and timeliness, shaping healthier futures for these children.
• Individual and Family Plans: Tailored to meet the diverse needs of individuals and families in a 15-county service area, our plans serve more than 13,000 members. Our extensive network, including renowned institutions like Ascension, Froedtert, and Medical College of Wisconsin, ensures comprehensive coverage both on and off the exchange.

What we offer:

• Thriving work environment: Immerse yourself in a vibrant, inclusive, and collaborative workplace that fosters creativity and innovation.
• Competitive compensation: Enjoy a competitive salary and benefits package that values your skills and dedication.
• Exceptional team dynamics: Join a team recognized for its top-notch employee engagement scores, making every day a rewarding experience.
• Impactful contribution: Seize the chance to create a positive impact in the lives of others, turning your passion into a meaningful difference.

Your opportunity:

We invite dedicated individuals to join our mission-driven organization. Be a part of something where your skills and enthusiasm translate into meaningful change. Discover a career where your passion meets purpose. Apply today and help us shape a healthier tomorrow.

Job Summary: Receives, reviews and processes prior authorization requests, and inpatient admissions, as it relates to eligibility, benefits and services across all lines of business to include Behavioral Health, Healthy Mom Healthy Baby and Physical Health. Resolves issues and educates internal and external staff and customers. Assists with the Clinical Services processes. Serves as a point of contact for Clinical Services providing assistance to providers, staff and other internal and external customers by maintaining communication, problem solving and resourcing. Routinely runs reports, maintains the member information for the Care Web system, maintains Clinical Services files, and accurately maintains the census. Creates provider accounts and field questions for the provider portal.

• Verifies eligibility, receives and enters the required member information for prior authorization either in an inpatient or outpatient setting and requests clinical and confirms admission status from hospitals.
• Constructs episodes for Out of Network (OON), this includes maintenance of OON provider and sanctions list. Constructs episodes Neonatal Intensive Care Unit (NICU) requests.
• Reconcile authorizations based upon status (no decision, no authorization required, or benefit denial).
• Create and maintains Salesforce and Care Web account for provider accounts on the provider portal.
• Educate and assist provider in navigating the provider portal. Retrieves and handles provider calls related to Medicaid and Together Marketplace. Identifies and refers provider concerns to Provider Relations for follow up.
• Act as a resource for investigating authorizations related to member and provider complaints and assists with appeal episode construction.
• Manages Right Fax for Clinical Services to include processing, routing and sending.
• Reviews authorizations for discrepancies as identified, modifies authorizations as needed to ensure transfer into the claims payment system, which includes reconciling infant temporary and permanent identification numbers.
• Assists with completion of Single Case Agreement Process.
• Generate daily census report and distribute. Generate OB delivery "Kick" report, newborn statistics report and forward to the state of Wisconsin weekly as well as post-partum mailer calendars and contact Exacta Graphics for pick up.

Education:

• High School graduate or Certificate of General Educational Development (GED) or High School Equivalency Diploma (HSED) Required

Experience:

• 1+ years prior experience in an insurance, healthcare, or managed care setting Required
• Managed care setting Preferred

Knowledge, Skills and Abilities:

• Working knowledge of medical terminology required.
• Utilizes good judgment and organizational ability to prioritize workload. Able to meet daily demands and deadlines, as well as respond to urgent situations.
• Strong communication, phone skills and organizational skills.
• Excellent customer service skills with a strong desire to solve problems and work with others
• Analytical ability to establish database, track, interpret, and report data.
• Ability to perform mathematic calculations at a level normally acquired through completion of high school
• Ability to read and write well enough to proof and edit correspondence and reports and maintain department record keeping systems.
• Well-versed in ICD 10 & CPT codes
• Excellent computer skills and well-versed in the Windows environment, including Microsoft Word, Excel, Outlook and PowerPoint.
• Strong data entry skills required.
• Ability to work independently and as part of a small team.

Required for All Jobs:

• This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that may be requested in the performance of this job.
• Employment is at-will. This document does not create an employment contract, implied or otherwise.

Children's Wisconsin is an equal opportunity / affirmative action employer. We are committed to creating a diverse and inclusive environment for all employees. We treat everyone with dignity, respect, and fairness. We do not discriminate against any person on the basis of race, color, religion, sex, gender, gender identity and/or expression, sexual orientation, national origin, age, disability, veteran status, or any other status or condition protected by the law.