Performs daily operational functions to effectively process authorization requests for full risk and shared risk group plans. Forwards and tracks requests to Utilization Review (UR) and processes determination upon return. Conducts research and communication with providers for retrospective or non-communicated authorizations when no authorization is on file or services are not properly authorized at the time of claim receipt. Assists providers and patients with process and status questions upon request from provider and member services departments. Maintains statistics and reports on authorization activity.
Knowledge of organizations policies, procedures, systems and objectives.
Knowledge of medical terminology, ICD-10, CPT and HCPCS coding required.
Trained in Health Insurance Portability and Accountability Act (HIPAA) general protocols with additional training specific to department as required & Security Policies and Procedures.
Proficient in Microsoft Office Products (Word, Excel, Outlook and Power Point).
Maintains professional and personal integrity.
Must be able to maintain effective working relationships with a wide variety of individuals.
Ability to deal diplomatically with all types of individuals under stressful situations.
Basic knowledge of medical terminology, anatomy and physiology.
Skill in developing comprehensive reports.
08.0 - 08:00 - 17:00 (United States of America)
Scheduled Weekly Hours
John Muir Health