Prior Authorization Specialist

Regal Medical Group•Los Angeles, CA

About The Position

The Prior Auth Specialist is responsible for assisting with the delivery of quality health care services. They must be proficient in all aspects of the prior auth process. They are responsible for supporting the clinician reviewers and medical directors as a resource for clarification and researching, complex member referral history for additional information needed in order to review the request based on medical necessity. They will monitor all their assigned referrals to ensure regulatory turnaround time compliance, assist with expediting finalization of referrals, and monitor requests that may require additional information prior to Regional Medical Director finalization. The Auth Specialist will work in collaboration with the department Prior Auth Coordinators, Team Leads, Supervisors, Department Director, Offshore Teams, Prior Authorization Nurses, Regional Medical Directors, and Network Managers to assist with daily operations and assuring a level of referral processing that meets or exceeds the organization’s expectation.

Requirements

High school graduate required
Minimum of 2+ years as a Prior Auth Coordinator
Proficient in principles of managed care.
Typing 60 words per minutes with accuracy.
Knowledge of computers, faxes, printers and all other equipment.
Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point).
Ability to deal with responsibility with confidential matters.
Ability to work in a multi-task, high energy environment.
Ability to prioritize.
Ability to meet deadlines and ensure regulatory compliance.
Ability to communicate appropriately and clearly with management, co-workers and physicians
Ability to operate PC based software programs or data base management systems
Must possess strong organizational skills and be detail oriented.
Proficient with turnaround time compliance in all aspects of the PA Process.
Ability to deal with responsibility with confidential matters.

Nice To Haves

Associates degree or higher preferred.
Experience with prior authorization process strongly preferred.

Responsibilities

Must be proficient in all aspects of the prior auth process.
Perform all Prior Auth Coordinator job functions.
Able to solve complex prior authorization questions and issues.
Effectively handle all incoming provider calls including the most challenging provider offices.
Identified trends with provider offices and interfaces with those provider offices.
Request Network Management training or on-site visit to provider offices needing reinforcement.
Identified issues that need to be escalated to a lead or supervisor.
Identify opportunities for improvement and make recommendations for change.
Understand the wants and needs of customers, listen for cues and identify how to respond and what level of intervention they need.
Communicate effectively and interact with the provider group and health plans daily or as indicated regarding Prior Authorization issues.
Return phone calls to providers and follow up with requests in a timely fashion.
“First line” resource for the clinicians and Medical Directors for outpatient referral inquiries.
Process request that are deferred and bring them to resolution.
Responsible for supporting the clinician reviewers and medical directors as a resource for clarification and researching, complex member referral history for additional information needed in order to review the request based on medical necessity.
Review each case with the established expectations for quality.
Capture any leakage and provide feedback to the leadership team for additional training.
Monitor all their assigned referrals to ensure regulatory turnaround time compliance, assist with expediting finalization of referrals, and monitor requests that may require additional information prior to Regional Medical Director finalization.
Work in collaboration with the department Prior Auth Coordinators, Team Leads, Supervisors, Directors, Prior Authorization Nurses, Regional Medical Directors, and Network Managers to assist with daily operations, training, auditing functions, and assuring a level of referral processing that meets or exceeds the organization’s expectation.
Recognize when an error has been made and immediately reports to appropriate Lead, Supervisor or Director.
Maintain quality monitors as assigned by Supervisor.
Complete assigned tasks accurately and within specified time limits.
Treat co-workers and customers with patience and respect.
Assist other staff and support the team approach.
Participates in the efficient, effective, and responsible use of resources such as supplies and equipment.
Communicate appropriately and clearly to management, co-workers, and physicians.
Arrives to work on time. Consistently be at work. Display flexibility regarding lunches, breaks and work hours.
Willingness to work overtime when requested.
Perform other duties as assigned.