Prior Authorization Coordinator I

Moda Health; Portland (OR); Remote; USD 29,000 - 33,000; Full time

Benefits offered by this job

Medical, Dental, Vision, Pharmacy,Life

401K Matching

FSA

Employee Assistance Program

PTO and Company Paid Holidays

Job summary

Moda Health in Oregon is seeking a Healthcare Services associate to support the Medical Management team. You will review referrals, determine prior authorization requirements, and educate members and providers on processes. This is a FT work-from-home role.

The position requires 1-2 years in a medical office or insurance environment, strong problem-solving, and excellent communication. You will collaborate with providers and manage daily admin tasks while ensuring HIPAA compliance.

Qualifications

• High school education or equivalent.
• 1-2 years of medical office or insurance experience.
• Strong problem-solving and decision quality.
• Knowledge of medical terminology and coding, claims adjudication and provider contracting.
• Proficient with PC and Microsoft Office.
• Excellent written, verbal, and interpersonal communication skills.
• Ability to interpret complex benefit packages and contract language.
• Maintain confidentiality.

Responsibilities

• Review and research referral and authorization requests.
• Determine the requirement for prior authorization based on plan type, ICD-10 code, CPT/HCPC code or place of service.
• Provide education to members and providers regarding prior authorization process.
• Interact with providers to gather complete, accurate information to process prior authorizations and referrals.
• Consult RN, Manager or Supervisor on complex cases.
• Manage daily administrative functions of the clinical team in Healthcare Services.
• Utilize Moda Health systems for documentation of contact with providers and members.
• Communicate with other Medical Management staff.
• Analyze claims and encounters according to limits of authorization and contracts.
• Adhere to HIPAA and regulatory guidelines.
• Audit daily work for accuracy, consistency and compliance.
• Maintain productivity expectations and meet deadlines.

Skills

Strong problem solving

Excellent communication

Organizational skills

Confidentiality

Education

High school diploma or equivalent

1-2 years medical office/insurance experience

Tools

PC proficiency

Microsoft Office

Facets UM

CT Dynamo

Job description

About Moda

Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.

Let’s do great things, together!

About Moda

Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.

Position Summary

This position will provide support to the Medical Management team by assisting in the investigation and research of prior authorization requests. Completes reviews or support the clinical staff in the review processes by preparing or completing the requests as assigned.

This is a FT WFH role.

Pay Range

$21.30 - $23.96 hourly (depending on experience).

Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.

Benefits

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

Required Skills, Experience & Education

• High school education or equivalent.
• 1-2 years of experience in a medical office and/or insurance experience needed.
• Strong problem-solving skills and decision quality preferred.
• High level of understanding of medical terminology and coding, state and federal regulations for claims adjudication and provider contracting.
• Knowledge of Health Plan benefits.
• Type a minimum of 35 wpm and 10key proficiency of 135spm on computer number keypad.
• Proficient with PC and Microsoft Office applications.
• Excellent written, verbal, and interpersonal communication skills including demonstrated business writing and grammar skills.
• Ability to interpret complex benefit packages and contract language.
• Excellent organizational and detail orientation skills.
• Ability to work independently, as well as part of a team, dealing with all levels of staff, members, providers, in a professional manner.
• Ability to maintain confidentiality.
• Ability to come to work on time and daily.
• Ability to work well under pressure, work with frequent interruptions and shifting priorities.
• Must present a professional business image in all settings.

Primary Functions

• Review and research referral and authorization requests received in Healthcare Services. Process or route per appropriate guideline.
• Determines the requirement for prior authorization based on the plan type, ICD-10 code, CPT/HCPC code or place of service.
• Provides education to members and providers regarding prior authorization process.
• Interacts with providers and provider offices to gather complete, accurate information to process prior authorizations and referrals and coordinates with providers to ensure consideration is given to unique treatment.
• Consults the RN, Manager or Supervisor on complex cases.
• Responsible for daily administrative functions of the clinical team in Healthcare Services, ensuring deadlines are met to support required processes of the clinical team, members and providers as well as facilitates the timely processing of documentation submitted to the Medical Management department.
• Utilizes the Moda Health systems for documentation of contact with providers and members.
• Communicates effectively with other Medical Management support staff.
• Analyze claims and encounters according to the limits of authorization, benefit plan and provider contracts.
• Effectively uses the Moda Health systems to accurately determine eligibility, benefit plan, and physician networks associated with the member’s plan.
• Completes approvals, and denials by the medical director, of claims and prior authorization requests in a professional, positive manner.
• Send proper correspondence to providers, members, and other departments to either obtain additional information necessary for the review of claims or denial of requested services.
• Analyze authorizations for correct information, such as authorization maximums, limitations, and special instructions for performance groups.
• Ensure adherence of Health Insurance Portability and Accountability Act (HIPAA) and other regulatory guidelines including privacy and security.
• Responsible for the auditing of individual daily work for accuracy, consistency and compliance based on Moda Health policies and procedures, state, federal and CMS (Medicare)/Medicaid regulations.
• Identifies problems and researches alternative solutions.
• Works with other team members to maintain the workflow to meet productivity and compliance standards.
• Completes other duties and special projects as assigned by the HCS Supervisor and/or the HCS Manager.
• Maintains an established productivity based on the complexity and demands of a heavy workload, complex services agreements, provider contracts and complex benefit packages.
• Responsible for utilizing all applicable policies, procedures and materials used in determining the proper review of claims, review, and processing of prior authorization requests for services.
• Enter data into appropriate system Facets UM or CT Dynamo must be able to accurately determine member eligibility and provider participation within a network.
• Maintain accurate patient note entry when not approving a request, when awaiting additional information or when routing the referral or preauthorization request.
• Perform other duties as assigned.

Working Conditions & Contact With Others

• Office environment with extensive close PC and keyboard use, constant sitting, and frequent phone communication. Must be able to navigate multiple computer screens. A reliable, high-speed, hard-wired internet connection required to support remote or hybrid work. Must be comfortable being on camera for virtual training and meetings. Work in excess of standard workweek, including evenings and occasional weekends, to meet business need.
• Internally with own department and Customer Service. Externally with Moda members, PBM vendor, providers, provider offices.

Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training.

For more information regarding accommodations, please direct your questions to Kristy Nehler & Danielle Baker via our [e-mail] email.