Prior Authorization Rep II

Summary/Position Objectives:
Under the guidance of a Prior Authorization Supervisor, this position is responsible for accurately processing requests for prior authorization in accordance with established guidelines, promptly responding to incoming calls and reporting pertinent information to other operational areas as appropriate.

Responsibilities:
Essential Functions:
Responds promptly to incoming provider requests for prior authorization and provides information and assistance necessary to meet provider needs and promote excellent customer service.
Triages inbound prior authorization requests using triage guidelines. If appropriate, refers request to nurse or medical director, or authorizes requested services using established prior authorization criteria and guidelines.
Enters accurately prior authorization data and related call tracking information to the Information System in accordance with established guidelines, including diagnosis of service and procedure codes.
Ensures data integrity by correctly entering PA data and reporting any identified discrepancies to a supervisor.
Gathers, sorts and tracks information as requested to meet business needs.
Identifies potential coordination of benefits (COB), third party liability (TPL), reinsurance and catastrophic cases. Reports information to the appropriate staff and/or supervisor.
Identifies and reports any system issues to supervisor for resolution.
Identifies and reports cases of probably/potential over/under utilization of services by both providers and members.
Identifies pregnant members and those members with asthma, diabetes, congestive heart failure and refers/call tracks to case or disease management proactively and appropriately.
Educates providers on prior authorization criteria and documents associated requests.
Identifies provider needs and refers to provider services for intervention.
Documents provider complaints and call tracks the complaints to provider services.

ABOUT SCHALLER ANDERSON:

Schaller Anderson administers Medicaid and employer self-funded health plans, and manages behavioral health plans. The company’s suite of services includes member services; provider services; claims processing; information services; financial reporting and analysis; medical management; and grievances and appeals services. Schaller Anderson has also been engaged in several consulting projects for states, health plans and providers. Schaller Anderson and its affiliates have 1,400+ employees nationwide and administer health plans with over 1.6 million members. Recently, the Initiative for a Competitive Inner City and Inc. magazine named Schaller Anderson to the Inner City 100, a list that recognizes the fastest-growing companies in America’s core urban areas. Schaller Anderson placed eighth among 5,000 entries in the Inner City 100 competition and was the only health care management company in the top 10.

The VISION of Schaller Anderson, Inc. is to be recognized as the nation’s foremost managed care resource by providing the highest value management and consulting services throughout the health care continuum.


BENEFITS:

Schaller Anderson team members are provided with countless opportunities to make a real difference and the following compensation/benefits:

* Competitive compensation DOE
* Medical, Dental and Vision insurance
* Employee Assistance Program
* Flexible spending accounts
* On-site fitness center (Phoenix headquarters only)
* Life insurance and accidental death and dismemberment insurance
* Short-term and long-term disability
* Paid holidays, paid time off/paid time off reserve
* 401(k) and profit sharing
* Tuition reimbursement
REQUIREMENTS
Knowledge and Skills:
Must be able to prioritize multiple tasks.
Demonstrates effective oral and written communication skills.
Proficient use of medical terminology, ICD-9, CPT and HCPC.
Successfully utilizes Microsoft Office, Windows, Excel, Information System, ESI and Encoder Pro
Apply medical criteria sets and triaging guidelines to Inbound Faxes.
Effective problem solving skills to procure data and information.

Education and Work Experience:
Bachelor degree in closely related field is preferred, although an equivalent combination of formal education and experience may substitute for a degree.
Minimum two (2) years telephone experience preferred
Minimum two (2) years of prior authorization experience preferred
Minimum three (3) years experience in a customer service, healthcare environment preferred