Job description
POSITION SUMMARY:
The Medicaid Clinical Prior Authorization Representative is responsible for taking incoming calls, providing
excellent customer service, working prior authorization, and ensuring that quality and timeliness standards are achieved.
PRIMARY RESPONSIBILITIES:
- Assist members and providers with clinical prior authorizations based on the State's policies and procedures and approved clinical practice guidelines and review criteria.
- Responsible for ensuring the appropriate medical record documentation is received for all clinical prior authorizations.
- Responsible for meeting turnaround times and other quality measures on a routine basis.
- Responsible for referring prior authorization requests for MDR review as appropriate.
- Responsible for reaching goals and quality on a daily basis.
- Other duties as assigned.
KNOWLEDGE, SKILLS, & ABILITIES:
- Ability to solve practical problems and deal with a variety of concrete variables in situations where some standardization exists;
- Ability to collect and analyze data, draw valid conclusions and actively contribute to the strategic interventions that support the departmental goals.
- Solid interpersonal skills
- Strong communication skills
- Impeccable professionalism and respect to all individuals
- Must demonstrate strong organizational skills; attentiveness to details; highly motivated with the ability to multi-task.
- Ability to communicate, facilitate and problem- solve with internal and external customers
- The ability and willingness to work as a team player.
- The ability to manage time and prioritize tasks.
- Must work independently as well as collaboratively within a team.
QUALIFICATIONS:
- RN or LPN with equivalent work experience.
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