Prior Auth Coordinator I - Temporary

Moda Health•Portland, OR

3d•Remote

About The Position

This temporary, work-from-home position supports Moda’s Medical Management team by investigating and researching prior authorization requests. The coordinator completes reviews or supports clinical staff by preparing or completing requests as assigned, processing or routing referral and authorization requests according to applicable guidelines, and helping ensure timely and accurate documentation and processing. The role involves determining prior authorization requirements based on plan type, codes, and place of service; reviewing claims and authorizations against plan benefits and provider contracts; and communicating with members, providers, and internal teams. The coordinator also helps maintain workflow, productivity, accuracy, and compliance with Moda policies and applicable regulatory requirements, including HIPAA.

Requirements

High school education or equivalent.
1–2 years of experience in a medical office and/or insurance experience.
Type at least 35 words per minute and demonstrate 10-key proficiency of 135 strokes per minute on a computer number keypad.
Proficiency with PC and Microsoft Office applications.
Strong written, verbal, and interpersonal communication skills, including business writing and grammar.
Ability to interpret complex benefit packages and contract language.
Excellent organizational skills and attention to detail.
Ability to work independently and as part of a team, interacting professionally with staff, members, and providers at all levels.
Ability to maintain confidentiality.
Ability to arrive at work on time and daily.
Ability to work under pressure with frequent interruptions and shifting priorities.
Ability to present a professional business image in all settings.
Ability to accurately determine member eligibility and provider participation within a network.
Ability to work more than 40 hours per week, including evenings and occasional weekends, as business needs require.

Nice To Haves

Strong problem-solving skills and sound decision quality.
A high level of understanding of medical terminology and coding, state and federal regulations for claims adjudication, and provider contracting.
Knowledge of health plan benefits.

Responsibilities

Review and research referral and authorization requests received by Healthcare Services, and process or route them according to applicable guidelines.
Determine prior authorization requirements based on plan type, ICD-10 code, CPT/HCPC code, or place of service.
Educate members and providers about the prior authorization process.
Contact providers and provider offices to obtain complete and accurate information, and coordinate consideration of unique treatment needs.
Consult the RN, Manager, or Supervisor about complex cases.
Perform daily administrative functions supporting the clinical team and facilitate timely processing of documentation for Medical Management.
Document contacts with providers and members in Moda Health systems and communicate effectively with Medical Management support staff.
Analyze claims and encounters according to authorization limits, benefit plans, and provider contracts.
Use Moda Health systems to determine member eligibility, benefit plans, and physician networks.
Complete approvals and medical-director denials of claims and prior authorization requests in a professional manner.
Send correspondence to providers, members, and other departments to obtain information needed for claim review or denial of requested services.
Analyze authorizations for accuracy, including maximums, limitations, and special instructions for performance groups.
Adhere to HIPAA and other regulatory privacy and security guidelines.
Audit individual daily work for accuracy, consistency, and compliance with Moda policies and procedures and state, federal, CMS, Medicare, and Medicaid regulations.
Identify problems, research alternative solutions, and work with team members to maintain workflow and meet productivity and compliance standards.
Complete other duties and special projects assigned by the HCS Supervisor or HCS Manager.
Maintain productivity appropriate to workload complexity, service agreements, provider contracts, and benefit packages.
Use applicable policies, procedures, and materials when reviewing claims and processing prior authorization requests.
Enter data into the appropriate Facets UM or CT Dynamo system and accurately determine member eligibility and provider network participation.
Maintain accurate patient notes when a request is not approved, additional information is pending, or a referral or preauthorization request is routed.
Perform other duties as assigned.