Prior Authorization Coordinator
Employment Information
Report this job
Job expired or something wrong with this job?
Job Description
Prior Authorization Coordinator reviewing Medicaid authorizations and medical necessity for CHNCT members. Applying InterQual criteria and coordinating provider denial communications.
Responsibilities:
- Work collaboratively with Health Services’ staff in conducting medical necessity review activities for Community Health Network members
- Approve or deny services based on benefit package and medical necessity criteria
- Respond to telephonic and written authorization and benefit coverage requests from CHNCT providers
- Conduct medical necessity reviews for DME, outpatient therapies, and inpatient and outpatient procedures
- Identify coordination of benefits needs and third-party liability
- Utilize InterQual and/or Medicaid criteria to make decisions
- Select, format, proofread, and print member and provider denial letters
- Refer cases to the CHNCT Medical Reviewer when clinical information does not support medical necessity
- Assist in educating providers on CHNCT policies and procedures
- Maintain knowledge of covered Medicaid benefits and share information with clinical staff
- Identify and refer cases for Intensive Care Management evaluation
- Escalate authorization issues to the Manager for resolution
- Review non-par and non-covered service requests and approve or deny them according to guidelines and policies
- Perform other duties as assigned
Requirements:
- Two years post-secondary schooling
- Associate's degree
- Licensed practical nursing major
- 3 to 5 years’ related experience
- Active Licensed Practical Nurse License
- Knowledge of covered benefits for Medicaid programs
- Ability to use InterQual and/or Medicaid criteria to make decisions
- Ability to conduct medical necessity reviews and determine benefit coverage
- Ability to review DME, outpatient therapy, inpatient and outpatient procedure authorization requests
Benefits:
- Medical, dental and vision coverage options
- Flexible spending and health savings accounts
- Group term life insurance
- A 401(k) plan with company-match and immediate vesting
- Voluntary accidental injury coverage
- Tuition reimbursement and continuing education opportunities
- A generous paid-leave bank and company holidays
- Wellness program
- Inclusive and accessible interview process with reasonable accommodations available
Similar Jobs
Tramitador, claro
Tramitador remoto de ventas de portabilidad para Partner Service, empresa de telecomunicaciones en Perú. Validando contratos, generando SEC y gestionando solicitudes comerciales.
ATC, Semi Full / Part Time
Asesor de atención al cliente trabajando remotamente para Partner Service, empresa transnacional de telecomunicaciones. Atención a clientes en turnos flexibles de mañana o tarde.
New Home Specialist
Part-time remote New Home Specialist generating leads and coordinating buyer appointments. Supporting First America Homes’ sales and marketing operations across Texas communities.
Process Server
Remote Process Server delivering legal documents for ProVest, a legal support services firm. Managing service attempts, route planning, and mobile-app updates across three North Carolina counties.
Process Server
Remote independent process server delivering legal documents for ProVest, a legal support services firm. Managing service attempts, route planning, and mobile-app updates across North Carolina counties.
Process Server
Process Server delivering legal documents for ProVest, a legal support services firm, across Harnett, Johnston, and Lee Counties. Managing service attempts independently using mobile apps.
Neuroscience Specialist
Neuroscience Specialist engaging Wichita Falls healthcare providers for Otsuka, a global pharmaceutical company. Delivering clinical product education, sales outreach, speaker programs, and local market insights.
Care Specialist, Part Time – Weekend Day Shift
Care Specialist providing empathetic chat and phone support for Empathy, which helps families navigate loss and major life transitions. Researching resources and managing Care Plans during weekend shifts.
Cash Application Coordinator
Cash Application Coordinator applying pharmaceutical receivables and reconciling remittances for SCRI, a community-based oncology clinical research organization. Supporting finance operations through accurate cash posting and discrepancy resolution.
Field Service Coordinator
Field Service Coordinator assessing Indiana members' needs and coordinating healthcare, LTSS, and community resources. Supporting Medicaid eligibility, service plans, and positive health outcomes for Humana.
Real Estate Entrepreneur
Entrepreneur indépendant développant une activité de conciergerie immobilière ALB à Reims. Prospection de propriétaires, gestion de logements et construction d’une équipe locale.
Real Estate Entrepreneur
Entrepreneur indépendant développant une activité de conciergerie immobilière ALB au Havre. Prospection de propriétaires, gestion de logements et construction d’une équipe locale.
Real Estate Entrepreneur
Entrepreneur immobilier lançant et développant une conciergerie locative sous la marque ALB. Prospection de propriétaires, gestion de logements et construction d’une équipe locale.
Real Estate Entrepreneur
Entrepreneur immobilier indépendant lançant une conciergerie ALB à Verdun. Prospection de propriétaires, gestion de logements et construction d’une équipe locale.
Real Estate Entrepreneur
Entrepreneur indépendant lançant et développant une conciergerie immobilière ALB. Prospection de propriétaires, gestion de logements et construction d’une équipe locale.
Real Estate Entrepreneur
Entrepreneur immobilier indépendant lançant une conciergerie locative courte durée sous la marque ALB. Prospection de propriétaires, gestion de logements et construction d’une équipe locale.
Real Estate Entrepreneur
Entrepreneur indépendant lançant et développant une activité de conciergerie immobilière ALB. Prospection de propriétaires, gestion de logements et construction d'une équipe locale.
Real Estate Entrepreneur – Property Concierge Services
Entrepreneur indépendant lançant et développant une activité de conciergerie immobilière ALB. Prospection de propriétaires, gestion de logements et construction d’une équipe locale.
Real Estate Entrepreneur
Entrepreneur indépendant lançant et développant une activité de conciergerie immobilière sous la marque ALB. Prospection de propriétaires, gestion de logements et construction d'une équipe locale.
Real Estate Entrepreneur – Concierge Services
Entrepreneur immobilier lançant et développant une activité de conciergerie ALB à Nantes. Prospection de propriétaires, gestion de logements et construction d’une équipe locale.