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Prior Authorizations Specialist

Orange, CA · Administrative
Prior Authorization Specialist - Managed Care
Orange, CA
Prior Authorization Specialist Job Summary:
  • 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 time-frames.
  • 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.
Prior Authorization Specialist 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.

623.201.8732 (CALL – TEXT – FAX)
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