Prior Authorization Representative - Texas STAR KidsPrimary Location: Dallas, TX
Additional Locations: TX-Dallas, TX-Ennis, TX-Grand Prairie, TX-Greenville, TX-Irving, TX-McKinney, TX-Plano, TX-Terrell Apply
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. This is an office-based position.
- Performs intake of calls from members or providers regarding services via telephone, fax, EDI.
- Utilizes Aetna system 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, COB, 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 PC monitor. Working environment includes typical office conditions.
- Responds promptly to incoming provider requests for prior authorization via telephone or fax and provides information and assistance necessary to meet provider/member needs and promote excellent customer service. Triages inbound prior authorization requests using triage guidelines. Enters data in accordance with established guidelines, including diagnosis of service and procedure codes. Ensures data integrity by correctly entering data and reporting any identified discrepancies to a supervisor. Gathers, sorts and tracks information as requested to meet daily business needs. Identifies and promptly reports any system issues to supervisor for resolution. Educates providers on the utilization management process and required documents. Identifies provider needs and refers to provider services for intervention.
- 2-4 years experience as a medical assistant, office assistant or other clinical experience.
- High School Diploma or G.E.D.
- Effective communication, telephonic and organization skills.
- Familiarity with basic medical terminology and concepts used in care management.
- Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members.
- Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word.
- Ability to effectively participate in a multi-disciplinary team including internal and external participants.
- Pediatric/adolescent experience is preferred
Jobs for you
Recently Viewed Jobs
You do not have any recently viewed jobs
Your Saved Jobs
You do not have any saved jobs
Sign up for Job Alerts
Join our Talent Community
At Aetna, a CVS Health Company, we are pioneering a total approach to health and wellness and we need talented candidates like you to join our team. Become a member of our talent community to be the first to know about career initiatives that match your skills and interests as they become available, in addition to details on upcoming events, networking opportunities, and news about Aetna, a CVS Health Company.Sign Up
Join Our Talent Community
Sign up to receive information about job openings that are tailored to your skills and interests. Plus, get the latest career news from Aetna, a CVS Health Company.