The Prior Authorization Representative supports comprehensive coordination of medical services including intake, screening and referrals to Aetna Medical Services Programs. Promotes/supports quality effectiveness of Healthcare Services.
This is a telework position. Qualified candidates may reside in or adjacent to any of the 9 regions: Jefferson, Two Rivers, SRT, Northern Bluegrass, Northeastern, Southern Bluegrass, Cumberland, The Lakes, or Eastern Mountain. Some travel to the Louisville office may be required for meetings and training.
Performs intake of calls from members or providers regarding services via telephone, fax, EDI.
Utilizes Aetna system to build, research and enter member information.
Screens requests for appropriate referral to medical services staff.
Approve services that do not require a medical review in accordance with the benefit plan.
Performs non-medical research including eligibility verification, COB, and benefits verification.
Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.
Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., claim administrators, Plan Sponsors, and third-party payers as well as member, family, and health care team members respectively).
Protects the confidentiality of member information and adheres to company policies regarding confidentiality.
Supports the administration of the precertification process in compliance with various laws and regulations, URAQ and/or NCQA standards, where applicable, while adhering to company policy and procedures.
Places outbound calls to providers under the direction of Medical Management Nurses to obtain clinical information for approval of medical authorizations.
Uses Aetna Systems such as QNXT, ProFAX, ProPAT, and Milliman Criteria. Communicates with Aetna Nurses, Case Managers and Medical Directors when processing transactions for members active in this Program.
Sedentary work involving significant periods of sitting, talking, hearing and keying. Work requires visual acuity to perform close inspection of written and computer-generated documents as well as a PC monitor. Working environment includes typical office conditions.
Experience or detailed knowledge of the Foster Care and juvenile justice systems, Adoption Assistance, the delivery of Behavioral Health Services, Trauma-informed Care, ACEs, Crisis Intervention services, and evidence-based practices applicable to the Kentucky SKY populations, is preferred.
High School Diploma or G.E.D.
2-4 years' experience as a medical assistant, office assistant or other clinical experience.
Computer literacy and demonstrated proficiency is required in order to navigate through internal/external computer systems, and MS Office Suite applications, including Word and Excel.
Additional Job Information
At Aetna Better Health of Kentucky, we reach beyond ensuring access to quality health care by focusing on resilient healing for children and their families. Our vision is to construct local, regional, and state-level coalitions to create a shared, in-common vision of health promoting and resiliency building approaches, to engage and support children to have membership in a family and community, while services and permanency planning are occurring. By keeping families safely together, children in Kentucky SKY will experience less trauma, which leads to better outcomes. To accomplish this, we are looking for people like you who value excellence, integrity, caring and innovation. As an employee, you'll join a team dedicated to supporting children, young people, parents, and other important partners involved with child protection systems. We value diversity and are dedicated to helping you achieve your career goals.
High School diploma, G.E.D. or equivalent experience
Percent of Travel Required
0 - 10%
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.