BusinessOperations - Authorization Specialist II - J00904

Position Purpose Acts as a resource and supports the prior authorization request process to ensure that all authorization requests are addressed properly in the contractual timeline. Supports utilization management team to document authorization requests and obtain accurate and timely documentation for services related to the members healthcare eligibility and access. Education/Experience Requires a High School diploma or GED Requires 1 – 2 years of related experience Knowledge of medical terminology and insurance preferred. Aids the utilization management team and maintains ongoing tracking and appropriate documentation on authorizations and referrals in accordance with policies and guidelines Supports the authorization review process by researching and documenting necessary medical information such as history, diagnosis, and prognosis based on the referral to the clinical reviewer for determination Verifies member insurance coverage and/or service/benefit eligibility via system tools and aligns authorization with the guidelines to ensure a timely adjudication for payment Performs data entry to maintain and update various authorization requests into utilization management system Supports and processes authorization requests for services in accordance with the insurance prior authorization list and routes to the appropriate clinical reviewer Remains up-to-date on healthcare, authorization processes, policies and procedures Performs other duties as assigned Complies with all policies and standards EEO “Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.” ======== Position Purpose Acts as a resource and supports the prior authorization request process to ensure that all authorization requests are addressed properly in the contractual timeline. Supports utilization management team to document authorization requests and obtain accurate and timely documentation for services related to the members healthcare eligibility and access. Education/Experience Requires a High School diploma or GED Requires 1 – 2 years of related experience Knowledge of medical terminology and insurance preferred. Aids the utilization management team and maintains ongoing tracking and appropriate documentation on authorizations and referrals in accordance with policies and guidelines Supports the authorization review process by researching and documenting necessary medical information such as history, diagnosis, and prognosis based on the referral to the clinical reviewer for determination Verifies member insurance coverage and/or service/benefit eligibility via system tools and aligns authorization with the guidelines to ensure a timely adjudication for payment Performs data entry to maintain and update various authorization requests into utilization management system Supports and processes authorization requests for services in accordance with the insurance prior authorization list and routes to the appropriate clinical reviewer Remains up-to-date on healthcare, authorization processes, policies and procedures Performs other duties as assigned Complies with all policies and standards Story Behind the Need What is the purpose of this team? What is driving this need? (ex. Backfill for FTE or CW, new project, business growth) Describe the surrounding team (team culture, work environment, etc.) & key projects. Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative? Ambetter OON and MCD OON Accountability, curiosity, courage, and service Team is three portions Redirection, Clinical Review, and Single Case Agreement Redirection to provide thoughtful steerage of members going Out of network back to an In network provider when appropriate for the Ambetter and MCD LOB. We will support the redirection aspect as well as support the single case agreement team. The SCA team obtains information from the authorization and submits the request to the respective contracting teams for Marketplace and MCD. Typical Day in the Role Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD). What are performance expectations/metrics? What makes this role unique? 8-5CST no weekends, no holiday rotations as a temp Will work Out of Network authorizations that flow through the day, some days are front loaded and other tasks come in throughout the day. Start of the day is reviewing assignment from the team lead and working cases throughout the day meeting target production requirements. Occasional calls to providers to clarify provider information however majority of day is working within our systems. Remote work environment, with active team collaboration through Microsoft teams Candidate Requirements Education/Certification Required: Highschool diploma or GED Preferred: Associates or certificate Licensure Required: NA Preferred Years of experience required: minimum 1-2 health experience or health insurance Disqualifiers: no prior health experience or health insurance, must have one Additional qualities to look for: Driven, with a growth mindset. Comfortable with frequent changes and directives. Top 3 must-have hard skills stack-ranked by importance 1 Skilled in researching network options, coordinating with providers, and accurately documenting activities in UM systems and tracking tools to ensure compliance and timely case resolution. 2 Prior auth or concurrent review experience or intake experience 3 Data awareness and productivity mindset Candidate Review & Selection Shortlisting process Candidate review & selection Interview information Onboard process and expectations Projected Manager Candidate Review Date: 3-5 days post shortlisting Type of Interviews Teams – camera on Required Testing or Assessment (by Vendor):