Position Purpose: Assist in monitoring utilization of medical services to assure cost effective use of medical resources through processing prior authorizations. Assist with monitoring the day to day operations of the staff including training staff.
Assist in coordinating the daily workflow of the Referral Specialist staff.
Receive, process, and data enter all authorization requests for physician, ancillary providers and internal requests to determine approval or denial as directed by the Medical Director.
Assist providers, members and/or internal customers with cases pertaining to referral questions, issues and authorizations.
Reconcile claims pended issues in a timely manner per health plan/department procedures.
Review and process denial letters, coordinate decisions to external or internal personnel per plan procedures.
Receive and review incoming phone and case management log reports and determine course of action (i.e., set up authorization or denial per Medical Director and/or plan guidelines).
Gather data and review ad hoc reports for special projects. Assist in the training and orientation of new employees and cross training of current employees.
Education/Experience: High school diploma or equivalent. 3 years of customer service, or related experience. Working knowledge of medical terminology preferred.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.