Prior Authorization Coordinator I

Moda Health•Portland, OR

4d•Remote

About The Position

The Prior Authorization Coordinator I supports the Medical Management team by investigating and researching prior authorization requests and preparing or completing reviews as assigned. This full-time, work-from-home position processes or routes referrals and authorization requests according to applicable guidelines, determines prior authorization requirements, and supports clinical staff with timely review and documentation. The coordinator interacts with members, providers, provider offices, and internal teams to obtain information, explain the authorization process, and help ensure requests are considered appropriately. The role also analyzes claims and authorizations, verifies eligibility and benefits, completes documentation and correspondence, and audits daily work for accuracy and compliance. The position requires a high-speed, hard-wired internet connection and comfort with virtual training and meetings. Work beyond the standard workweek, including evenings and occasional weekends, may be required to meet business needs. The listed hourly pay range is $21.30–$23.96, depending on experience and qualifications.

Requirements

High school education or equivalent.
1–2 years of experience in a medical office and/or insurance.
Understanding of medical terminology and coding, state and federal regulations for claims adjudication, provider contracting, and health plan benefits.
Ability to type at least 35 words per minute and achieve 135 strokes per minute on a 10-key computer number keypad.
Proficiency with PCs and Microsoft Office applications.
Excellent written, verbal, and interpersonal communication skills, including business writing and grammar.
Ability to interpret complex benefit packages and contract language.
Strong 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.
Reliable attendance and punctuality.
Ability to work under pressure, manage frequent interruptions, and adapt to shifting priorities.
Professional business image in all settings.
Ability to maintain productivity amid heavy workloads, complex service agreements, provider contracts, and benefit packages.
Reliable high-speed, hard-wired internet connection for remote or hybrid work.
Comfort with being on camera for virtual training and meetings.

Nice To Haves

Strong problem-solving skills and decision quality are preferred.

Responsibilities

Review and research referral and authorization requests received in Healthcare Services, then 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 gather complete and accurate information and coordinate consideration of unique treatment needs.
Consult an RN, Manager, or Supervisor on complex cases.
Perform daily administrative functions for the clinical team and help ensure deadlines and timely processing of documentation are met.
Document contacts with providers and members in Moda Health systems.
Communicate effectively with other 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 additional information or communicate claim or service denials.
Analyze authorizations for correct information, including maximums, limitations, and special instructions for performance groups.
Comply with HIPAA and other regulatory privacy and security guidelines.
Audit individual daily work for accuracy, consistency, and compliance with company policies and procedures and state, federal, CMS, Medicare, and Medicaid regulations.
Identify problems, research alternative solutions, and collaborate with team members to meet workflow, productivity, and compliance standards.
Use applicable policies, procedures, and materials to determine appropriate claim reviews and prior authorization processing.
Enter data into the appropriate system, including Facets UM or CT Dynamo, and accurately determine member eligibility and provider network participation.
Maintain accurate patient notes when a request is not approved, is awaiting additional information, or is routed for review.
Perform other duties and special projects assigned by the HCS Supervisor or HCS Manager.