Job Details

Description

• Analyzes, researches, and interprets medical and claims data while processing authorization requests. This includes:
• Authorizes requests that clearly meet specified criteria according to department guidelines.
• Refers requests to Medical Directors for determination when appropriate following department and regulatory guidelines.
• Ensures necessary medical record information, previous review determinations, and other member-specific data are sufficient to make determinations.
• Requests any missing information according to medical policy and benefit guidelines following department standards and regulatory statutes. Ensures requests are processed within regulatory timeliness guidelines.
• Maintains productivity rate and meets requirements for accuracy and timeliness for Private Business.

• Communicates final case determinations in writing and by telephone, providing complete and accurate information using appropriate templates per department and regulatory guidelines. Documents accurately and completely in a timely manner.
• Resolves incoming routine inquiries from members and providers received by telephone, correspondence, or email.
• Ensures quality outcomes by tracking, researching, and documenting updated benefit/medical policy information, unit workflows, inquiry resolution, and participating in quality improvement activities such as inter-rater reliability reviews.
• Performs all other miscellaneous responsibilities and duties as assigned or directed.

#LI-Hybrid

Qualifications

• Associates degree and one year of related work experience or an equivalent combination of education and/or experience.
• Effective written and verbal communication skills.
• Basic knowledge of Microsoft Office applications, including but not limited to Word, Excel, and Outlook.