Prior Authorization Coord I Job Title Prior Authorization Coord I Duration Open until filled Description Let’s do great things, together! About ModaFounded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together. Position SummaryThis position will provide support for the Medical Management team by assisting in the investigation and research of prior authorization requests. Completes reviews or support the clinical staff in the review processes by preparing or completing the requests as assigned.This is a FT WFH role. Pay Range$19.05 - $23.81 ​​​hourly*Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range. Please fill out an application on our company page, linked below, to be considered for this position. https://j.brt.mv/jb.do?reqGK=27748840&refresh=trueBenefits: + Medical, Dental, Vision, Pharmacy, Life, & Disability + 401K- Matching + FSA + Employee Assistance Program + PTO and Company Paid Holidays Required Skills, Experience & Education: + High school education or equivalent. + 1-2 years of experience in a medical office and/or insurance experience needed. + Strong problem-solving skills and decision quality preferred. + High level of understanding of medical terminology and coding, state and federal regulations for claims adjudication and provider contracting. + Knowledge of Health Plan benefits. + Type a minimum of 45 wpm and 10-key proficiency of 135 spm on computer number keypad. + Proficient with PC and Microsoft Office applications. + Excellent written, verbal, and interpersonal communication skills including demonstrated business writing and grammar skills. + Ability to interpret complex benefit packages and contract language. + Excellent organizational and detail orientation skills. + Ability to work independently, as well as part of a team, dealing with all levels of staff, members, providers, in a professional manner. + Ability to maintain confidentiality. + Ability to come to work on time and daily. + Ability to work well under pressure, work with frequent interruptions and shifting priorities. + Must present a professional business image in all settings. Primary Functions: + Review and research referral and authorization requests received in Healthcare Services. Process or route per appropriate guidelines. + Determines the requirement for prior authorization based on the plan type, ICD-10 code, CPT/HCPC code or place of service. + Provides education to members and providers regarding prior authorization process. + Interacts with providers and provider offices to gather complete, accurate information to process prior authorizations and referrals and coordinates with providers to ensure consideration is given to unique treatment. + Consults the RN, Manager or Supervisor on complex cases. + Responsible for the daily administrative functions of the clinical team in Healthcare Services, ensuring deadlines are met to support the required processes of the clinical team, members and providers as well as facilitating the timely processing of documentation submitted to the Medical Management department. + Utilizes the Moda Health systems for documentation of contact with providers and members. + Communicate effectively with other Medical Management support staff. + Analyze claims and encounters according to the limits of authorization, benefit plan and provider contracts. + Effectively uses the Moda Health systems to accurately determine eligibility, benefit plan, and physician networks associated with the member’s plan. + Completes approvals, and denials by the medical director, of claims and prior authorization requests in a professional, positive manner. + Send proper correspondence to providers, members, and other departments to either obtain additional information necessary for the review of claims or denial of requested services. + Analyze authorizations for correct information, such as authorization maximums, limitations, and special instructions for performance groups. + Ensure adherence to the Health Insurance Portability and Accountability Act (HIPAA) and other regulatory guidelines including privacy and security. + Responsible for the auditing of individual daily work for accuracy, consistency and compliance based on Moda Health policies and procedures, state, federal and CMS (Medicare)/Medicaid regulations. + Identifies problems and research alternative solutions. + Works with other team members to maintain the workflow to meet productivity and compliance standards. + Completes other duties and special projects assigned by the HCS Supervisor and/or the HCS Manager. + Maintains an established productivity based on the complexity and demands of a heavy workload, complex services agreements, provider contracts and complex benefit packages. + Responsible for utilizing all applicable policies, procedures and materials used in determining the proper review of claims, review, and processing of prior authorization requests for services. + Entering data into appropriate system Facets UM or Clinical Care Advance (CCA) must be able to accurately determine member eligibility and provider participation within a network. + Maintain accurate patient note entry when not approving a request, when awaiting additional information or when routing the referral or preauthorization request. + Perform other duties as assigned. Working Conditions & Contact with Others: + Internally with own department and Customer Service. Externally with Moda members, PBM vendors, providers, provider offices. + Office environment with extensive close PC and keyboard work, constant sitting, and phone work. Must be able to navigate multiple screens. Work in excess of 40 hours per week, including evenings, early mornings and rotating weekends, to meet business need. Together, we can be more. We can be better. ​​​​Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training. For more information regarding accommodations please direct your questions to Kristy Nehler via our humanresources@modahealth.com email.