Prior Authorization Coordinator I

Moda Health•Portland, OR

2d•Remote

About The Position

This position will provide support to the Medical Management team by assisting in the investigation and research of prior authorization requests. Completes reviews or support the clinical staff in the review processes by preparing or completing the requests as assigned. This is a FT WFH role.

Requirements

High school education or equivalent.
1-2 years of experience in a medical office and/or insurance experience needed.
High level of understanding of medical terminology and coding, state and federal regulations for claims adjudication and provider contracting.
Knowledge of Health Plan benefits.
Type a minimum of 35 wpm and 10key proficiency of 135spm on computer number keypad.
Proficient with PC and Microsoft Office applications.
Excellent written, verbal, and interpersonal communication skills including demonstrated business writing and grammar skills.
Ability to interpret complex benefit packages and contract language.
Excellent organizational and detail orientation skills.
Ability to work independently, as well as part of a team, dealing with all levels of staff, members, providers, in a professional manner.
Ability to maintain confidentiality.
Ability to come to work on time and daily.
Ability to work well under pressure, work with frequent interruptions and shifting priorities.
Must present a professional business image in all settings.

Nice To Haves

Strong problem-solving skills and decision quality preferred.

Responsibilities

Review and research referral and authorization requests received in Healthcare Services.
Process or route per appropriate guideline.
Determines the requirement for prior authorization based on the plan type, ICD-10 code, CPT/HCPC code or place of service.
Provides education to members and providers regarding prior authorization process.
Interacts with providers and provider offices to gather complete, accurate information to process prior authorizations and referrals and coordinates with providers to ensure consideration is given to unique treatment.
Consults the RN, Manager or Supervisor on complex cases.
Responsible for daily administrative functions of the clinical team in Healthcare Services, ensuring deadlines are met to support required processes of the clinical team, members and providers as well as facilitates the timely processing of documentation submitted to the Medical Management department.
Utilizes the Moda Health systems for documentation of contact with providers and members.
Communicates effectively with other Medical Management support staff.
Analyze claims and encounters according to the limits of authorization, benefit plan and provider contracts.
Effectively uses the Moda Health systems to accurately determine eligibility, benefit plan, and physician networks associated with the member’s plan.
Completes approvals, and denials by the medical director, of claims and prior authorization requests in a professional, positive manner.
Send proper correspondence to providers, members, and other departments to either obtain additional information necessary for the review of claims or denial of requested services.
Analyze authorizations for correct information, such as authorization maximums, limitations, and special instructions for performance groups.
Ensure adherence of Health Insurance Portability and Accountability Act (HIPAA) and other regulatory guidelines including privacy and security.
Responsible for the auditing of individual daily work for accuracy, consistency and compliance based on Moda Health policies and procedures, state, federal and CMS (Medicare)/Medicaid regulations.
Identifies problems and researches alternative solutions.
Works with other team members to maintain the workflow to meet productivity and compliance standards.
Completes other duties and special projects as assigned by the HCS Supervisor and/or the HCS Manager.
Maintains an established productivity based on the complexity and demands of a heavy workload, complex services agreements, provider contracts and complex benefit packages.
Responsible for utilizing all applicable policies, procedures and materials used in determining the proper review of claims, review, and processing of prior authorization requests for services.
Enter data into appropriate system Facets UM or CT Dynamo must be able to accurately determine member eligibility and provider participation within a network.
Maintain accurate patient note entry when not approving a request, when awaiting additional information or when routing the referral or preauthorization request.
Perform other duties as assigned.