Department(s): Utilization Management, Prior Authorization
Reports to: Supervisor, Prior Authorization
FLSA status: Non-Exempt
Salary Grade: C – $41,000 – $53,000
Job Summary
The Medical Authorization Assistant (MA) provides office and referral management services. The MA serves as a contact between members, physicians, providers and CalOptima staff, processing initial intake of information, assisting with authorization functions, and gathering information. Position 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/functions related to CalOptima’s prior authorization and referral process. Responsible for applying CalOptima’s medical criteria and policies/procedures to authorization or referral requests from medical professionals, clinical facilities, and ancillary providers. Directly interact with provider callers, acting as a resource for their needs. The position operates under the direction of the licensed Nurse.
Position Responsibilities:
Receives referral request via fax, phone, or electronically and data enters new service request information into the authorization system.
Collects additional information from CalOptima members and/or providers to complete referral information.
Authorizes requested services according to CalOptima’s authorization guidelines, performing data entry into the authorization system, and verifying eligibility.
Contacts the Health Networks and/or CalOptima Customer Service regarding health network enrollments.
Assists the authorization Nurse in gathering medical records, obtaining appropriate coding for diagnosis and procedures, and follow 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 and tracking, trending of events and other relevant databases as needed.
Other projects and duties as assigned.
Knowledge & Abilities:
Explain and obtain relevant required data from members, providers, etc., to record and summarize findings.
Communicate clearly and concisely, both verbally and in writing as well as with individuals from diverse backgrounds.
Develop and maintain effective working relationships with all levels of staff, other programs, community agencies, providers, and members.
Use prior authorization protocols to determine when to refer matters to a licensed staff person.
Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Experience & Education:
High school diploma or equivalent required.
2+ years of experience in a Healthcare / Managed Care setting required.
Preferred Qualifications:
Bilingual in English and in one of CalOptima’s defined threshold language (English, Spanish, Vietnamese, Farsi, Arabic, Korean, and Chinese) is preferred.
Prior Authorization and Utilization Management process preferred.
Knowledge of:
Medical Terminology.
Medi-Cal and Medicare benefits and regulations.
Current ICD 10- CPT, and Healthcare Common Procedure Coding System (HCPCS) Coding continual updates to knowledge base regarding the codes.
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.
Job Location: Orange, California
Position Type:
To apply, visit https://jobs.silkroad.com/CalOptima/Careers/jobs/3289
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