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Aetna is now a CVS Health Company

West Virginia Medicaid Prior Authorization Representative

Primary Location: Charleston, WV
Additional Locations: WV-Charleston
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Description:
The Prior Authorization Representative supports comprehensive coordination of medical services including intake, screening and referrals to Aetna Medical Services Programs. Promotes/supports quality effectiveness of Healthcare Services.

Fundamental Components:
  • Performs intake of calls from members or providers regarding services via telephone, fax, electronic data interchange.
  • Utilizes Aetna systems to build, research and enter member information.
  • Screens requests for appropriate referral to medical services staff.
  • Approve services that do not require a medical review in accordance with the benefit plan.
  • Performs non-medical research including eligibility verification, coordination of benefits, and benefits verification.
  • Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.
  • Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., claim administrators, Plan Sponsors, and third party payers as well as member, family, and health care team members respectively)
  • Protects the confidentiality of member information and adheres to company policies regarding confidentiality
  • Communicate with Aetna Case Managers, when processing transactions for members active in this Program
  • Supports the administration of the precertification process in compliance with various laws and regulations, URAQ and/or NCQA standards, where applicable, while adhering to company policy and procedures.
  • Places outbound calls to providers under the direction of Medical Management Nurses to obtain clinical information for approval of medical authorizations.
  • Uses Aetna Systems such as QNXT, ProFAX, ProPAT, and Milliman Criteria.
  • Communicates with Aetna Nurses and Medical Directors, when processing transactions for members active in this Program.
  • Sedentary work involving significant periods of sitting, talking, hearing and keying. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a personal computer monitor.


Background Experience:
  • 2-4 years’ experience as a medical assistant, office assistant or other clinical experience.
  • Previous experience working with providers and provider networks preferred.
  • Call center experience, strongly preferred.


Additional Job Information:
Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of West Virginia is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of our members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of West Virginia, and we will support you all the way.

Required Skills:
Benefits Management - Interacting with Medical Professionals, Finance - Managing Aetnas Risk, General Business - Applying Reasoned Judgment

Desired Skills:
General Business - Communicating for Impact, General Business - Consulting for Solutions, General Business - Demonstrating Business and Industry Acumen

Technology Experience:
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel

Potential Telework Position:
No

Percent of Travel Required:
0 - 10%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Candidate Privacy Information:
Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Click To Review Our Benefits (PDF)

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