Responsible for screening prior-authorization and coordination of specialized services requests in the medical care management program, including a broad range of requests for inpatient, outpatient and ancillary services. Adheres to policies and procedures in order to comply with performance and compliance standards and to ensure cost effective and appropriate healthcare delivery. Maintains current knowledge of network resources for referral and linkage to member’s and provider’s needs. Authorizes certain specified services, under the supervision of the manager, according to departmental guidelines. Per standard workflows, forwards specified requests to the clinician for review and processing.  Answers ACD line calls from providers and other departments and redirects, as needed.

KEY FUNCTIONS/RESPONSIBILITIES:

• Prioritizes incoming Prior Authorization requests.
• Processes incoming requests, including authorizing specified services, as outlined in departmental policies, procedures, and workflow guidelines.
• Refers authorization requests that require clinical judgment to Prior Authorization Clinician, Manager, or Medical Director.
• Meets or exceeds position metrics and Turn-Around Timeframes while maintaining a full caseload.
• Supports Prior Authorization Clinicians.
• Answers ACD line calls, verifies member eligibility and enters into CCMS or Facets the information necessary to complete the caller’s request.
• Identifies and informs callers of network providers, services, and available member benefits.
• Informs provider of decision per department procedure.
• Coordinates resolution of escalated member or provider inquiries as related to Prior Authorization.
• Works with members, providers and key departments to promote an understanding of Prior Authorization requirements and processes.
• Maintains general understanding of applicable sections of member handbooks, evidence of coverage, and BMHCP extranet.

QUALIFICATIONS:

EDUCATION:

• Associate’s Degree or the equivalent combination of training and experience is required.
• Current MA LPN license preferred.
• Knowledge of medical terminology and/or coding preferred.

EXPERIENCE:

• 1 year of office experience, specifically in either a high volume data entry office, customer service call center or health care office or hospital administration is required.

PREFERRED/DESIRABLE:

• Experience with FACETS or other healthcare database.
• Experience with Health Plan Utilization / Claims departments.
• Customer service experience.

COMPETENCIES, SKILLS, AND ATTRIBUTES:

• Bi-lingual preferred.
• Excellent customer service skills.
• Ability to prioritize work load when processing referrals and authorization requests pre guidelines and within specified Turn Around Timeframes.
• Ability to process high volume of requests with a 95% or greater accuracy rate.
• Effective collaborative skills.
• Strong oral and written communication skills.
• A strong working knowledge of Microsoft Office products.

 *Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.

Required Skills Required Experience