Essential Functions

Prior Authorizations:  Obtain necessary medical/clinical information utilizing multiple sources including use of specific medical group electronic health records by following SCMG/PHMG documented operational processes.  Accurately interpret external criteria and internal operational documents.  Ensure medical necessity criteria selected is appropriate for the referral request being reviewed.  Document in the referral management system, according to SCMG/PHMG operational processes, actions taken on each referral processed including, but not limited to telephone calls made to obtain needed information, documentation of actions taken related to the processing of the referral.  Attach corresponding documents to the referral within the referral management system in OnBase.  Refer referral requests for review by licensed staff and Medical Directors within required turn-around times (TAT).  Serve as a liaison to the Case Management team and assist with obtaining requested information.

Benefit Verification: Ability to proficiently navigate health plan web sites.  Verify member eligibility status.  Obtain detailed benefit coverage for service requests in accordance with the member's benefit plan coverage.  Accurately interpret health plan benefits.  Apply the benefit guidelines to approve referral requests as outlined in the SCMG/PHMG prior authorization document and desktop procedures.  Research and assist in the benefit denial process by utilizing SCMG operational documents to obtain necessary documentation, such as member specific health plan Evidence of Coverage (EOC), health plan coverage criteria, etc.

Retrospective Review: Coordinate, review, and process retrospective claims for medical care and services including, but not limited to emergency room visits, urgent care visits, outpatient care, medical transportation, and durable medical equipment supplies.  Ensure the retrospective claims review process is completed within the required regulatory turn-around times (TAT).  Provide a determination for services that designated on the PAR document as well as the SCMG/PHMG operation documents as appropriate for approval at the UM Care Coordinator level of review.  Appropriately identify claims for review by the Medical Director to include obtaining the appropriate medically necessary criteria or benefit documents.  Accurately complete the eMD for and forward the claim with all applicable information to the Medical Director.

Job Requirements

Minimum Education: High School or equivalent

Preferred Education: Medical Administrative or Insurance Specialist Certified

Minimum Experience: 0-12 months in the medical field or Managed Care setting

Preferred Experience: 2 Years in healthcare setting

Required License: Not Applicable

Preferred License: Not Applicable

Required Certification: Not Applicable

Preferred Certification: Medical Administrative or Insurance Specialist Certified