Bilingual Authorization Coordinator (Spanish/English)

This position is responsible for servicing the needs of Members, providers and the Health Plans representatives, by effectively handling referrals from providers to facilitate the clinical review, issue authorizations and coordination of referrals services utilizing pre-approved screening criteria in compliance with contracted Client's requirements and adopted clinical guidelines. Handles the more complex requests for treatment and authorization requests. Conducts searches on authorization requests to handle complex Provider inquiries.

Essential Functions & Responsibilities

  • Receives referral requests from providers and Health Plans representatives. Assist in processing medical services request. Completes clerical duties related to the processing of Authorization Requests and Provider Referrals.
  • Verifies member’s eligibility and benefits with subsequent notification to designated staff of eligibility issues.
  • Inputs all requests for services received via fax or phone into the system accurately for electronically generated authorization and tracking.
  • Provides services authorizations to providers per UM Departmental Policy and Procedures and specific contracted Client's process on a timely manner.
  • Requests submission of appropriate medical records according to established criteria for requested service(s) in accordance with the corresponding Policy and Procedure.
  • Notifies required parties within the appropriate timeframe for routine and urgent requests for services.
  • Researches member history for duplications and consideration of authorization limits.
  • Verifies fax numbers and system updates. Communicates with requesting provider for any identified need to clarify a request for an authorization, such as CPT codes, ICD10, requested timeframes and member’s demographics.
  • Provides effective departmental communication with both internal and external sources.
  • Forwards Authorizations to appropriate department staff in terms of eligibility and other coverage, pricing, and benefit issues.
  • Scans, attaches, reviews and effectively works with electronic images as part of the authorization process. Including recording the required information from attachments into the authorization fields.
  • Collaborates with Supervisor, Network and Claims Department Staff to resolve complex authorization issues.
  • Appropriately forwards all referral requests to the next level of clinical review as applicable and after verifying for completeness and appropriateness.
  • Coordinates approved outpatient surgical procedures in specialist's office and/or outpatient surgical facilities with health plan's authorization department when applicable.
  • Coordinates approved services with Home Health Providers, Plan discharge Planners and Plan Members as delegated or required by Plan.
  • Is resource person for PCP to refer to network specialist(s).
  • Distributes correspondence and other information to the appropriate parties or departments.
  • Maintains appropriate logs, records, and reports as established by Utilization Department.
  • Documents and communicates areas of concern to supervisor.
  • Identifies providers who show an educational need to follow national, state and plan requirements.
  • Adheres to company HIPAA policies and procedures. Identifying, maintaining and protecting sensitive HIPAA information (PHI) and following procedures to ensure the security of such information.
  • Ensures integrity of data entry is accurate.
  • Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
  • Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
  • Ability to come to work and work the regular schedule and shift for the position.
  • Compliance with all personnel policies and procedures.
  • Perform additional duties and related essential duties as assigned.

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Education and/or Experience

  • High school diploma or general education degree (GED); Medical coding or authorization education/training preferred.
  • Required computer literacy and advanced data entry capacity (++45 wpm)
  • Required Bilingual (Spanish/English)
  • Experience processing/managing referrals or authorization requests in a Utilization Management department for 2 years and at least 1 year of experience with Health System One as an Authorization Coordinator-I, demonstrating production and accuracy well above the minimum required goals, or an equivalent combination of education and experience, which would provide the required knowledge, skills and abilities may also be qualifying.

Certificates, Licenses, Registrations

Preference will be given to medical assistants, certified nursing assistants and allied medical professionals.

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