Title: Prior Authorization Specialist
Location: Charlestown, MA
- Responsible for screening prior-authorization and coordination of specialized services requests in the medical care management program, including a broad range of requests for inpatient, outpatient and ancillary services.
- Adheres to policies and procedures in order to comply with performance and compliance standards and to ensure cost effective and appropriate healthcare delivery.
- Maintains current knowledge of network resources for referral and linkage to member's and provider's needs. Authorizes certain specified services, under the supervision of the manager, according to departmental guidelines.
- Per standard workflows, forwards specified requests to the clinician for review and processing. Answers ACD line calls from providers and other departments and redirects, as needed.
- Prioritizes incoming Prior Authorization requests.
- Processes incoming requests, including authorizing specified services, as outlined in departmental policies, procedures, and workflow guidelines.
- Refers authorization requests that require clinical judgment to Prior Authorization Clinician, Manager, or Medical Director.
- Meets or exceeds position metrics and Turn-Around Timeframes while maintaining a full caseload.
- Supports Prior Authorization Clinicians.
- Answers ACD line calls, verifies member eligibility and enters into CCMS or Facets the information necessary to complete the caller's request.
- Identifies and informs callers of network providers, services, and available member benefits. • Informs provider of decision per department procedure.
- Coordinates resolution of escalated member or provider inquiries as related to Prior Authorization.
- Works with members, providers and key departments to promote an understanding of Prior Authorization requirements and processes.
- Maintains general understanding of applicable sections of member handbooks, evidence of coverage, and client extranet. Supervision Exercised:
- None Supervision Received: Direct supervision weekly
Qualification and Experience:
- 1 year of office experience, specifically in either a high volume data entry office, customer service call center or health care office or hospital administration is required.
- Experience with FACETS or other healthcare database.
- Experience with Health Plan Utilization / Claims departments.
- Customer service experience.
Certification or Conditions of Employment
- Pre-employment background check Competencies, Skills, and Attributes:
- Bi-lingual preferred.
- Excellent customer service skills.
- Ability to prioritize work load when processing referrals and authorization requests pre guidelines and within specified Turnaround Timeframes.
- Ability to process high volume of requests with a 95% or greater accuracy rate.
- Effective collaborative skills.
- Strong oral and written communication skills.
- A strong working knowledge of Microsoft Office products. Working Conditions and Physical Effort:
- Regular and reliable attendance is an essential function of the position.
- Ability to work OT during peak periods. (Non-Exempt Positions)
- Work is normally performed in a typical interior/office work environment.
- No or very limited physical effort required. No or very limited exposure to physical risk.