Pre-Authorization Specialoist II

Location: Thousand Oaks
Posted on: November 14, 2024

Job Description:

GENERAL SUMMARY:

This position is responsible for receiving and filling requests for information from providers and members, processing prior authorization requests, administering notification of medical services, inpatient hospitalization requests, and processing incoming calls.

QUALIFICATIONS:

High School Diploma/GED required

Knowledge in medical terminology, ICD-9/CPT Coding preferred

1 - 3 years health care experience preferred

Demonstrates problem-solving skills

Strong computer/typing skills

Excellent oral and written communication skills

Excellent listening skills

Strong service orientation with professional and courteous performance

Flexible and adaptable to quick changing environment(s)

Ability to work as a team player in a professional environment

Prior Authorization experience preferred.

SKILLS / REQUIREMENTS

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Process requests for Prior Authorization

a) Treatment request

b) Inpatient hospitalization

c) Phone requests

Verify eligibility within the database system to members and providers.

Code each diagnosis of service and procedures according to standards.

Handle telephone requests timely and accurately.

Update plan resources.

Inform Provider Relations of non-contracted providers.

Analyze daily faxed requests to determine coverage and approval utilizing criteria. Utilize nurses for medical reviews when necessary.

CORPORATE INTEGRITY:

Understands and abides by all departmental policies and procedures as well as the organizations Corporate Integrity Program.

Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct Class.

Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.

Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare.

MM decision making is based only on appropriateness of care and service and existence of coverage.

We do not specifically reward practitioners or other individuals for issuing denials of coverage of service or care.

Financial incentives for MM decision makers do not encourage decisions that result in underutilization.

Keywords: , Bakersfield , Pre-Authorization Specialoist II, Healthcare , Thousand Oaks, California