Prior Authorization Technician - Remote - United States

Position Summary: 

The purpose of the Prior Authorization Technician is to work cooperatively with licensed clinical staff to provide patients and physicians with accurate and timely determination of the prior authorization requests based on clinical guidelines. The Prior Authorization Technician will assist in maintaining compliance of the prior authorization processes and turnaround time requirements.

Position Reports to:

• This position reports to the Director of Operations and requires minimal degree of supervision to ensure tasks are appropriately prioritized.

Job Duties and Essential Functions:

• Responsible for providing timely referral determination by accurate:
  • Usage of the Milliman Care Guidelines
  • Identification of referrals to the medical director for review
  • Appropriate letter language and coding (denials, deferrals, modifications)
  • Appropriate selection of the preferred and contracted providers
  • Proper identification of eligibility and health plan benefits
  • Proper coding to trigger the record to be routed to a different work queue or to trigger the proper determination notice to be sent out
• Responsible for maintaining compliance in turn around time requirements as mandated by the ICE TAT Standards
• Continuous monitoring of the pended documents
• Responsible for working closely with supervisor/lead to address issues and delays that can cause a failure to meet or maintain compliance.
• Responsible for maintaining the performance standard of one ninety (60) status 1, 2, 3, referrals per day.
• Responsible for processing OB deliveries by entering the following information in Ezcap:
  • Admit date
  • Discharge Date
  • Type of delivery (vaginal or c-section)
  • Appropriate Milliman Care guidelines
  • Case Summary
• Attends all mandatory trainings
• Maintains and keeps in total confidence, all files, documents and records that pertain to the operation of business of Cap Management Systems.
• All other job related duties as it relates to the job function …