Remote Prior Authorization Specialist

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

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.