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Prior Authorizations SpecialistOrange, CA · Administrative
Prior Authorization Specialist - Managed Care
Prior Authorization Specialist Job Summary:
Prior Authorization Specialist Background
- 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.
- 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.