Medical Authorization Specialist

Health Partners Plans; Philadelphia (Philadelphia County); On-site; USD 28,000 - 39,000; Full time

Job summary

Health Partners Plans seeks an Authorization Coordinator to collect and process inpatient and outpatient authorization requests using the Medical Management system, provider portal, and call center functions. The role facilitates authorizations through technical and payment cycles and supports case managers with timely information.

The position requires a high school diploma, 2 years of health care experience, and strong proficiency in Microsoft Office, medical terminology, and communication.

Qualifications

• 2 years in health care experience
• Proficient use of Microsoft Office suite (Word, PowerPoint, Excel) required
• Knowledge of medical terminology, utilization review systems, hospital admission systems, health care claims or medical office administration
• Demonstrate ability to work and communicate effectively with co-workers, members and providers at the owner institutions
• Ability to work independently and as a team player
• Ability to work on detailed reports
• Demonstrate excellent organizational skills and ability to competently handle multiple responsibilities at one time
• Demonstrate excellent telephone and verbal/written communication skills

Responsibilities

• Follow all company and department policy and procedures.
• Process and create authorizations requests for emergency admissions, elective inpatient admissions, outpatient services in a medical and home setting, DME emergent and urgent maternity and newborn delivery admissions as per departmental guidelines.
• Identify duplication of services and communicate to appropriates team members.
• Follow up to confirm outstanding prior authorizations to confirm status and update system and authorization.
• Manage authorizations coming through the provider portal via the 278 transaction into Medical management system and perform quality assurance of all required fields prior to reassignment to appropriate case manager.
• Responsible to process all cases assigned by leadership.
• Monitors and prepares clinical information and record maintenance for submission to QIO (Quality Improvement Organization).
• Create cases for non -par providers with a temporary provider ID and collect pertinent provider information and refer via Medical Management System to Network Management team for completion of MHS set up for claims payment.
• Monitor provider portal for failed and duplicate authorizations for provider re-education.
• Provide continuous call center telephone service in a prompt and courteous manner. Maintaining call service thresholds.
• Verify member's eligibility via internal eligibility system and/ or DHS terminal and alert case managers of change in eligibility status.
• Code all services accurately using appropriate ICD-10 codes CPT and HCPCS coding systems.
• Reconcile claim discrepancies via Service forms sent and meet the Service Level Agreement of (3) three business days turnaround time.
• Identify resolution of outstanding claims issues generated by a provider inquiry and or written request.
• Assist member services and provider services in addressing member or provider questions regarding service authorization questions and, general customer service for both internal and external customers.
• Support Clinical Case Managers by closing cases when applicable.
• Maintain Key Indicator thresholds for established phone service for the department
• Triage of Medical Management clinical faxes for timely medical necessity review.
• Attach faxes to the member's case in (Medical Management System).
• Work with Applications Systems Management (ASM) team to identify system failures that directly impact claim payment and data integrity

Skills

Healthcare experience

Microsoft Office

Medical terminology

Education

High School Diploma or GED

Tools

Medical Management System

Job description

Health Partners Plans seeks an Authorization Coordinator to collect and process inpatient and outpatient authorization requests using the Medical Management system, provider portal, and call center functions. The role facilitates authorizations through technical and payment cycles and supports case managers with timely information.

The position requires a high school diploma, 2 years of health care experience, and strong proficiency in Microsoft Office, medical terminology, and communication.