Job Description

• Analyzes, researches, and interprets medical and claims data while processing authorization requests. This includes:
• Authorizes requests that clearly meet specified criteria according to department guidelines.
• Refers requests to Medical Directors for determination when appropriate following department and regulatory guidelines.
• Ensures necessary medical record information, previous review determinations and other member-specific data are sufficient to make determinations.
• Requests any missing information according to medical policy and benefit guidelines following department standards and regulatory statutes.Ensures requests are processed within regulatory timeliness guidelines.
• Maintain productivity rate and meet requirements for accuracy and timeliness for Private Business.
• Communicates final case determinations in writing and by telephone providing complete and accurate information using appropriate templates per department and regulatory guidelines. Documents accurately and completely in a timely manner.
• Resolves incoming routine inquiries from members and providers received by telephone, correspondence or email.
• Ensures quality outcomes by tracking, researching and documenting updated benefit/medical policy information, unit workflows and inquiry resolution as well as participating in quality improvement activities such as inter-rater reliability reviews.
• Performs all other miscellaneous responsibilities and duties as assigned or directed.

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