Prior Authorization Rep

Job Description

Job Description

Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing whole-person care to Senior and Medicaid populations, through advanced value-based models. Our provider network is comprised of more than 6,000 health care providers, including primary and specialty care physicians, hospitals and ancillary providers. We have operated in the Arizona market for more than 14 years, based in Chandler, Arizona, and are an affiliate of Heritage Provider Network. As a leading value-based provider organization, we are committed to improving the quality of care, providing excellent member and provider experiences all while reducing cost.

The Prior Authorization Representative I is responsible for processing incoming requests including verifying eligibility and benefits and the data entry component of the prior authorization request. The PA Rep I works closely with all UM Staff, Prior Auth Supervisor, and management to maintain turnaround time requirements of the contracted health plan, regulatory bodies, and internal goals. Routinely interacts with physicians, their office staff and internal customers.

POSITION DUTIES & RESPONSIBILITIES

• Assist in managing the incoming prior authorization request by following work direction given by the Prior Authorization management to ensure Routine/Standard and Urgent/Expedited prior authorizations are processed in the appropriate amount of time and in compliance with regulatory and health plan requirements.
• Complete a minimum data entry or adjudication of 40 authorizations per day.
• Assist in reviewing and distributing incoming prior authorization requests including identifying Urgent/Expedited vs Routine/Standard, verifying member eligibility, delegated vs non-delegated services, retro vs. future date of services, accuracy checking documentation, and routing to appropriate folder.
• Perform data entry of prior authorization requests with a minimum of 97% accuracy including primary insurance or hospice verification, determine if requested services require prior authorization, and confirm request is not duplicative.
• Perform adjudication of authorization requests with a minimum of 97% accuracy including quality checking data entry, reviewing historical utilization management history to include program enrollment and verifying if rendering provider and facility is contracted, any tasks related to processing a prior authorization request (provider loads, out of network (OON) credentialing, accreditation verification, etc.), providing redirect information for OON requests, and routing to the appropriate queue or vendor.
• Contact the provider's office for additional information per CMS and AZPC policies and guidelines.
• Make expedited determination notifications to member and provider.
• Provide exceptional, courteous, and professional phone customer service.
• Educate practitioners as needed with the Authorization/Referral process.
• Perform as necessary accommodate to departmental change, workload and emergencies.
• Maintain current knowledge of CMS and NCQA standards, and AZPC UM Policies and procedures.
• Protect privacy for patients, providers, and employees; ensure all personal health information is kept confidential.
• Demonstrate caring, empathy, patience, respect and compassion for all team members.
• Demonstrate honesty and integrity in everyday activities.
• Perform other duties as directed by management.

EDUCATION, TRAINING AND EXPERIENCE

• Highschool Diploma or GED – Required.
• Minimum of 1-year administrative healthcare related experience – Required.
• Proficient knowledge of medical terminology, CPT-4, HCPCS, and ICD-10 – Required.
• Working knowledge of computer applications, such as Microsoft Office applications.
• Excellent oral and written communication skills.
• Demonstrated ability to be detail-oriented and multi-task effectively.
• Able to interact effectively with all levels of staff.

*This role requires 60 days FT in office presence, hybrid options will be available after the 60-day period.*