Prior Authorization RepresentativePrimary Location: Richmond, VA
Additional Locations: VA-Richmond Apply
- Performs intake of calls from members or providers regarding services via telephone, fax, EDI.Utilizes eTUMS and other 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.
- Receives inbound calls from providers. Requests providers to send in clinical information for the Medical Management Nurses to review the clinical information for approval or denial of medical authorizations
- Uses Aetna Systems such as QNXT, ProFAX, ProPAT. 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.
- 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.
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