DEPARTMENT(S):  Utilization Management, Prior Authorization REPORTS TO:  Supervisor, Prior Authorization FLSA STATUS:  Non-Exempt SALARY GRADE:  C - $20.81 - $28.03 ($43,281 - $58,300)

ABOUT CALOPTIMA HEALTH

CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto — "Better. Together.” — is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community’s health.  We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring.  CalOptima Health has been recognized as one of Orange County’s best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! 

ABOUT THE POSITION

The Medical Authorization Assistant (MAA) provides office and referral management services. The MAA serves as a contact between members, physicians, providers, and CalOptima Health staff, as well as processing initial intake of information, assisting with authorization functions, and gathering information. The incumbent is responsible for reviewing and processing requests for authorization and notification of medical services from health professionals, clinical facilities, and ancillary providers. The incumbent is responsible for tasks related to CalOptima Health’s prior authorization and referral process. The MAA is responsible for applying CalOptima Health’s medical criteria and policies/procedures to authorization or referral requests from medical professionals, clinical facilities, and ancillary providers. The incumbent directly interacts with provider callers, acting as a resource for their needs. The MAA operates under the direction of the licensed nurse.

DUTIES AND RESPONSIBILITIES:

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Receives referral request via fax, phone, or electronically and enters new service request information into the authorization system.
• Collects additional information from CalOptima Health members and providers to complete referral information.
• Authorizes requested services according to CalOptima Health’s authorization guidelines, performing data entry into the authorization system, and verifying eligibility.
• Contacts the health networks and CalOptima Health Customer Service regarding health network enrollments.
• Assists the authorization nurse in gathering medical records, obtains appropriate coding for diagnosis and procedures, and follows up on phone calls as directed by the authorization nurse.
• Documents all contacts and case information in the system using the standard charting format.
• Performs data entry into the appropriate databases for monitoring, tracking, and trending of events, and other relevant databases as needed.
• Completes other projects and duties as assigned.

EXPERIENCE & EDUCATION:

• High School diploma or equivalent required.
• 2 years of experience in a healthcare or Managed Care setting required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

PREFERRED QUALIFICATIONS:

• Bilingual in English and in one of CalOptima Health's defined threshold language (English, Spanish, Vietnamese, Farsi, Arabic, Korean, and Chinese) preferred.
• Prior Authorization and Utilization Management process knowledge preferred.

ABOUT OUR BENEFITS & WELLNESS OPTIONS:

At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.

_CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. _

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.  You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.

Required Skills Required Experience