| Position Purpose: Leads the prior authorization request process to ensure work queue is managed and addressed properly. Provides guidance and expert knowledge to utilization management team on documenting the most complex authorization requests to ensure accurate and timely documentation for services related to the members healthcare eligibility and access. Education/Experience: Requires a High School diploma or GED Requires 4+ years of related experience. Assesses and analyzes member insurance coverage and/or service/benefit eligibility via system tools and aligns authorization with the guidelines to ensure a timely adjudication for payment Reviews authorization requests to ensure authorization requests are documented in the utilization management system and are in accordance with policies and procedures Develops in-depth knowledge of prior authorization review process and insurance coverage including responding to complex or escalated authorization requests Maintains ongoing tracking and appropriate documentation on authorizations and referrals in accordance with policies and guidelines Act as a subject matter expert as well as a trainer to other team members for the overall authorization process and for multiple service types at different levels of urgency Oversees the authorization review process of utilization management team members researching and documenting necessary medical information such as history, diagnosis, and prognosis based on the referral to the clinical reviewer for determination Assists with aging reports and audits Reviews escalations and works on resolving them in a timely manner Assists with reporting on authorization volumes and alignment on staffing assignments. Ensures referrals are addressed in a timely manner by service providers and clinical reviewers. Leads, oversees, and maintains authorization requests for services in accordance with the insurance prior authorization list Remains up-to-date on healthcare, authorization processes, policies and procedures Expert knowledge of medical terminology and insurance Performs other duties as assigned Complies with all policies and standards | |||||
| Story Behind the Need Business Group & Key Projects | |||||
| The Centralized Transplant Unit (CTU) will be short-staffed nurses during the months of November through February due to maternity leave, sick leave, vacations and holiday time off. We would like to use three (3) non-clinical team members to help manage primarily non-clinical work that is currently being managed by the nursing team. By managing this workload with a non-clinical team, it will free up the available nurses to manage the strictly nursing tasks (transplant listings, contracting, etc.). | ||||
| Typical Day in the Role | |||||
| 8am - 6pm CST, Monday through Friday with flexible scheduling permitted, some overtime, possible occasional weekend periodic check-ins. Assess member insurance coverage/service/benefit eligibility via clinical documentation tools, document auth requests in UM systems, adherence to TAT & complex authorization requests, builds and completes transplant evaluation requests, validates contracting and sets up P2P. Will interact with other Transplant Program Coordinators, Clinical Staff, Leadership Team, Health Plans and National Contracting. Remote work environment. | ||||
| Compelling Story & Candidate Value Proposition | |||||
| High impact, complex, specialized work that supports member access to potentially life-saving transplant care. Works within one of healthcare s most complex & meaningful service areas. Partnership with clinical teams, policy experts, contracting and Population Health. Gain expertise in transplant operations, benefit structures, and policy interpretation. | ||||
| Candidate Requirements | |||||
| Education/Certification | Required: High School Diploma or Equivalent, minimum of 4 years in health care operations, Prior Authorization. Microsoft Office Suite (Word, Excel, Outlook, Teams, Zoom) | ||||
| Licensure | NA | Preferred: | |||
| Must haves : Medical Terminology, Proficiency in Microsoft office, ability to manage multiple priorities in a fast-paced setting, critical thinking (can apply sound judgement to complex authorization scenarios and identifies and escalate issues when necessary) excellent attention to detail, strong interpersonal and written communication skills with clinical and non-clinical audiences. Understands and can adhere to regulatory (TAT), policy (and workflows) and audit requirements. Can maintain productivity standards and accuracy amid frequent process changes or evolving program requirements. Demonstrates service excellence=empathy, responsiveness, professionalism in all members, provider and stakeholder interactions. Culture of curiosity whereby ongoing development in transplant processes, payer policy and healthcare operations. Strong Data Entry Skill Nice to haves : Prior Authorization, Claims Processing, Excellent organizational skills, familiarity with clinical documentation or claims systems (Trucare Classic, Cloud, Facets, Care Central) Disqualifiers: Any candidate that doesn t possess the must-haves. Performance indicators: Turnaround time and Production dashboards | ||||
| 1 | Medical Terminology | |||
| 2 | 4+ years of healthcare operations experience that includes UM processes, such as PA/intake | ||||
| 3 | Microsoft Office Suite Experience | ||||
| Candidate Review & Selection | |||||
| Projected HM Candidate Review Date: | 1-2 days post shortlisting | |||
| Number and Type of Interviews: | 2 maximum per candidate, one with Supervisor and Director and one with VP if necessary via MS Teams | ||||
| Extra Interview Prep for Candidate: | None | ||||
| Required Testing or Assessment (by Vendor): | Medical Terminology, Microsoft Office Suite (if possible) | ||||
| Manager Communication Preferences & Next Steps | |||||
| Basic background check | ||||
| Yes, in December | ||||
| Carmin Pruitt, Lindsey Ramos | ||||