Job Duties
- Receives referral requests from providers and check-out desk. Assist in processing medical services requested. Completes clerical duties related to the processing of Authorization Requests and Provider Referrals.
- Verifies member’s eligibility and benefits with subsequent notification to designated staff of eligibility issues.
- Inputs all requests for services received via fax or phone into the system accurately for electronically generated authorization and tracking.
- Provides services authorizations to providers per UM Departmental Policy and Procedures and specific contracted Client's process on a timely manner.
- Requests submission of appropriate medical records according to established criteria for requested service(s) in accordance with the corresponding Policy and Procedure.
- Notifies required parties within the appropriate timeframe for routine and urgent requests for services.
- Researches member history for duplications and consideration of authorization limits.
- Verifies fax numbers and system updates. Communicates with requesting provider for any identified need to clarify a request for an authorization, such as CPT codes, ICD10, requested timeframes and member’s demographics.
- Provides effective departmental communication with both internal and external sources.
- Forwards Authorizations to appropriate department staff in terms of eligibility and other coverage, pricing, and benefit issues.
- Scans, attaches, reviews and effectively works with electronic images as part of the authorization process. Including recording the required information from attachments into the authorization fields.
- Collaborates with Supervisor, Network and Claims Department Staff to resolve complex authorization issues.
- Appropriately forwards all referral requests to the next level of clinical review as applicable and after verifying for completeness and appropriateness.
- Coordinates approved outpatient surgical procedures in specialist's office and/or outpatient surgical facilities with health plan's authorization department when applicable.
- Coordinates approved services with front desk staff & scheduling coordinators.
- Is resource person for PCP to refer to network specialist(s).
- Maintains appropriate logs, records, and reports as established by Utilization Department.
- Documents and communicates areas of concern to supervisor.
- Adheres to company HIPAA policies and procedures. Identifying, maintaining and protecting sensitive HIPAA information (PHI) and following procedures to ensure the security of such information.
Education
- High school diploma or general education degree (GED); Medical coding or authorization education/training preferred.
Experience & Skills Required
- Required: computer literacy and advanced data entry capacity (++45 wpm)
- Required: Bilingual (Spanish/English)
- Experience processing/managing referrals or authorization requests in a Utilization Management department for 2 years, demonstrating production and accuracy well above the minimum required goals, or an equivalent combination of education and experience, which would provide the required knowledge, skills and abilities may also be qualifying.
Job Type: Full-time
Pay: $20.00 - $24.00 per hour
Expected hours: 40 per week
Benefits:
- 401(k)
- Health insurance
- Paid time off
Weekly day range:
Ability to Relocate:
- Glendale, CA 91203: Relocate before starting work (Required)
Work Location: In person