Prior Authorizations Specialist

Location: Orange, CA
Date Posted: 06-29-2018
Prior Authorizations Specialist - Managed Care
Orange, CA
Your Job Summary:
The role of the Prior Authorization Specialist is to assist Utilization Review nurses by screening Prior Authorization and coordination of specialized services requests, including a broad range of requests for inpatient, outpatient and ancillary services.  The purpose of the Prior-Authorization, or Pre-Certification, process is to promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to Prior Authorization requests.  The Prior Authorizations Specialist is essential to ensuring that prior authorization requests are completed in a timely fashion to meet contractual requirements.  Maintains current knowledge of network resources for linking member and provider needs.  Authorizes certain specified services, under the supervision of the manager and according to established departmental guidelines. Per standard workflows, forwards specified requests to the clinician for review and processing.  Additionally, the Specialist answers inbound calls from providers and other departments and redirects, as needed.
Your Background:
Requires an education level of at least a high school diploma or GED; Associate’s or Bachelor’s degree is a plus.
Prefers, but does not require, a Certified Nurse Assistant (CNA) or Medical Assistant (MA).
Requires exceptional phone / customer service skills, as well as very strong computer user skills.
At least 1-2 years’ Prior Authorization, Claims, Utilization Review, or Care Coordination experience.
Prefer around 1 year at a Managed Care Organization (Health Plan, IPA/Medical Group, HMO, TPA/MSO, etc).
Requires basic to intermediary familiarity with Medical terminology (1-3 years direct experience).
Ability to multi-task duties as well as the ability to understand multiple products and multiple levels of benefits within each product.
Knowledge of health care delivery system, Medicaid/Medicare and related state programs is required.
Computer skills to include Microsoft Word, Excel and basic data entry, including the ability to learn new and complex computer system applications.
Must have a minimum of 30-40 wpm typing with a high level of accuracy.
Prefer Candidates Bilingual in English and one more: Spanish, Vietnamese, Korean, Chinese (Mandarin or Cantonese), or Farsi.

Your Duties:
  • Screens and prioritizes incoming Prior Authorization requests.
  • Supports clinical staff (nurses, physicians, etc) involved in the Prior Authorization process.
  • Processes incoming requests, including completing the authorization for specific and limited services, based on established guidelines.
  • Forwards authorization requests that require clinical judgment to Prior Authorization nurse, Manager, or Medical Director.
  • Maintains a full caseload while meeting or exceeding designated metrics and turn-around timeframes.
  • Answers inbound calls from providers and other departments, verifies member eligibility and enters the information necessary to complete the caller’s request into the designated database.
  • Identifies and informs callers of network providers, services, and any other available member benefits.
  • Informs providers of the decision on their requests, per department procedure.
  • Assists with the resolution of escalated member or provider inquiries related to Prior Authorization.
  • Serves as subject matter expert for members, providers, and internal departments to promote an understanding of Prior Authorization requirements and processes.
480.425.2451 (CALL – TEXT – FAX)
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