Authorization Specialist II

Position Summary:

Acts as a resource and supports the prior authorization request process to ensure that all authorization requests are addressed properly in the contractual timeline. Supports utilization management team to document authorization requests and obtain accurate and timely documentation for services related to the members healthcare eligibility and access.

Key Responsibilities:

* Aids the utilization management team and maintains ongoing tracking and appropriate documentation on authorizations and referrals in accordance with policies and guidelines

* Supports the authorization review process by researching and documenting necessary medical information such as history, diagnosis, and prognosis based on the referral to the clinical reviewer for determination

* Verifies member insurance coverage and/or service/benefit eligibility via system tools and aligns authorization with the guidelines to ensure a timely adjudication for payment

* Performs data entry to maintain and update various authorization requests into utilization management system

* Supports and processes authorization requests for services in accordance with the insurance prior authorization list and routes to the appropriate clinical reviewer

* Remains up-to-date on healthcare, authorization processes, policies and procedures

* Performs other duties as assigned

* Complies with all policies and standards

Qualification & Experience:

* Requires a High School diploma or GED

* Requires 1 - 2 years of related experience

* Knowledge of medical terminology and insurance preferred.