Prior Authorization Specialist

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Job Description:

Position Summary:  Evaluates referral and pre-certification requests in accordance with contractual obligations.  Regularly interacts with physician offices assisting with prior authorizations.

COMPETENCIES/Role-Specific Functions: 

COMMUNICATION

Communicates well both verbally and in writing, creates accurate and punctual reports, delivers presentations, shares information and ideas with others, has good listening skills.

• Develops and maintains a good working relationship with team members, other departments, medical directors, and provider offices.

PROBLEM SOLVING

Breaks down problems into smaller components, understands underlying issues, can simplify and process complex issues, understands the difference between critical details and unimportant facts.

• Answer phones regarding questions related to prior authorization.

PRODUCTIVITY

Manages a fair workload, volunteers for additional work, prioritizes tasks, develops good work procedures, manages time well, handles information flow.

• Follows documented process to review healthcare service requests.

SELF DEVELOPMENT

Seeks out and accepts feedback, is a proactive learner, takes on tough assignments to improve skills, keeps knowledge and skills up-to-date, turns mistakes into learning opportunities.

CUSTOMER FOCUS

Builds customer confidence, is committed to increasing customer satisfaction, sets achievable customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met, solicits opinions and ideas from customers, responds to customers.

• Participates as a part of the Prior Authorization team by actively interacting with other team members to distribute work fairly and resolve issues.

JOB KNOWLEDGE

Understands duties and responsibilities, has necessary job knowledge, has necessary technical skills, understands company mission/values, keeps job knowledge current, is in command of critical issues.

• Evaluates referral and pre-certification requests to determine eligibility and network affiliation.

Qualifications (Education/Experience/Knowledge/Skills/Abilities): 

• High School diploma/GED; MA or Associates degree highly preferred
• One to three years healthcare experience required (medical office, healthplan, etc.)
• One to three years utilization management experience highly preferred
• Knowledge of medical terminiology required
• Knowledge of medical coding, NCQA and Medicare Guidelines required
• Proven customer service skills required
• Excellent written and verbal communications skills required
• Skilled in computer competency using Microsoft Outlook, Word and Excel
• Ability to work in a windows based environment utilizing numerous programs at once
• Ability to work in a fast pace environment
• Ability to identify and sovle practical problems
• Ability to maintain positive and effective work relationships with coworkers, clients, members, and providers.
• Strong organizational skills.
• Strong attention to detail.
• Home office that is HIPAA compliant for all remote or telecommuting positions as outlined by the company policies and procedures. 

Salary Range:

$19.71 - $26.28