The Medical Authorization Assistant provides office and referral management support services; assists the inpatient Case Managers in obtaining medical records, documenting all case information in the system, performing data entry into appropriate databases for monitoring and tracking, and following up on phone calls as directed by the Case Managers. This position serves as the contact between members, physicians, facilities, providers and CalOptima staff. Responsible for processing the intake information and assisting with authorization functions. May also perform office support functions as required.
- Receives inpatient requests via fax, phone, or electronically; enters data of the new case information into the medical management system.
- Creates inpatient events based on facility face sheets and/or clinical received.
- Verifies member eligibility.
- Collects additional information from CalOptima members and/or providers/facilities to complete prospective, concurrent or retrospective inpatient service reviews.
- Authorizes requested services according to CalOptima’s Concurrent Review Team guidelines. Contacts the health networks and/or CalOptima Customer Service regarding health network enrollments.
- Assists the inpatient Case Manager in gathering medical records, obtaining appropriate coding for diagnosis and procedures, discharge dates, dispositions, and conducts follow up phone calls per concurrent review team standards.
- Documents all contacts and case information in the system using the standard charting format.
- Data enters into the appropriate databases for monitoring and tracking, trending of inpatient events and other relevant databases as needed.
- Completes discharge follow up duties as assigned.
- Other projects and duties as assigned.
- Communicate clearly and concisely both verbally and in writing formats.
- Communicate with individuals from diverse backgrounds.
- Utilize Concurrent Review protocols to determine when to refer matters to licensed staff.
- Develop and maintain interpersonal relationships internally/externally with; all levels of staff, other programs’ staff, community agencies, providers and members.
- Utilize computers, keyboarding and appropriate software (e.g. Microsoft Office applications and job specific applications) to produce correspondence, charts, spreadsheet, and/or other information applicable to the position assignment.
Experience & Education:
- High school diploma or equivalent required.
- 2 years of related experience that would provide the knowledge and abilities listed required.
- Medical billing, Coding or Medical Assistant certification strongly preferred.
- Bilingual in English and one of CalOptima’s defined threshold languages is preferred.
- Medical terminology.
- ICD-10 and CPT coding.
- Medi-Cal and Medicare benefits and regulations.