Performs daily operational functions to effectively process authorization requests for full risk and shared risk group plans. Forwards and tracks requests to Utilization Review (UR) and processes determination upon return. Conducts research and communication with providers for retrospective or non-communicated authorizations when no authorization is on file or services are not properly authorized at the time of claim receipt.
Assists providers and patients with process and status questions upon request from provider and member services departments. Maintains statistics and reports on authorization activity.
High School Graduate or Equivalent Preferred
Health Maintenance Organization Referrals Required Certifications/Licensures: Epic - Proficiency must be passed within 90 days of Start Date Required
Knowledge of organizations policies, procedures, systems and objectives. Knowledge of medical terminology, ICD-10, CPT and HCPCS coding required. Trained in Health Insurance Portability and Accountability Act (HIPAA) general protocols with additional training specific to department as required & Security Policies and Procedures.
Proficient in Microsoft Office Products (Word, Excel, Outlook and Power Point). Maintains professional and personal integrity. Must be able to maintain effective working relationships with a wide variety of individuals.
Ability to deal diplomatically with all types of individuals under stressful situations. Basic knowledge of medical terminology, anatomy and physiology. Skill in developing comprehensive reports.
Work
08.0 Per Diem No Waive
$27.03 - $36.50 Hourly Offer amounts are based on demonstrated/relevant experience and/or licensure. Pay will be adjusted to the local market if hired outside of the Bay Area . Note: Positions at JMH which are exempt (not eligible for overtime) under the level of Manager are listed as hourly for compensation purposes on this posting.
The work shift will contain the word ‘exempt’ on it. Scheduled Weekly Hours: 0