Authorizations Clerk

Authorization ClerkUnder the direction of the Administrative Supervisor, this position is responsible to enter requests for authorization accurately within UM systems utilized; including verification of member eligibility, demographics, health plan identification, appropriate entry of referring and requested providers, diagnosis and procedure coding based on referral submission. The Authorization Clerk will interact with other departments, clinic personnel, and outside providers in a professional and friendly manner, to create and maintain a positive relationship with our internal and external customers. Responsibilities include: Maintaining incoming referral submissions on a continuous basis throughout the day. Efficient daily sorting and distribution of pending referrals and documentation amongst Authorization Clerk team. Review of each requested referral submission for possible stat and/or urgent referral submission every 15 minutes. Verification of member eligibility by means of UM systems utilized and/or Health Plan eligibility websites. Communicate new or termed member status with the Eligibility department, in efforts to maintain up to date eligibility status in systems utilized. Accurate input and verification of requested referral submissions to include; correct member, referring provider, requested provider, facility, place of service, diagnosis (ICD-10) coding, procedure (CPT/HCPC) coding and quantity. Accurately classify requested referrals based on urgency indicated by the referring provider or member; such as stat, urgent, routine, retro, or medication. Input of all expedite and medication referrals must be handled as top priority due to regulation turnaround times. Input of all routine and retro referrals must be organized and processed in a timely manner to maintain compliance with regulation turnaround times. Compile and document good faith attempts in obtaining medical records for each requested referral when there is lack of information. Adherence to internal approval guidelines pertaining to the Authorization clerk's auto approval rules. Appropriate forwarding of requested referrals to the next level of UM review, when internal approve guidelines are not met. Abide by turnaround time standards and regulations set forth by the Health Plan and CMS. Maintaining of electronic referral submission reports. Communicating with physician offices, processing staff and other departments as needed to ensure collaboration and open discussion regarding referral process. Including responding to messages within next business day. Maintains current knowledge base with regards to rules, regulations, polices and procedures relating to prior authorization process. Adaptable to regulation and necessary departmental procedure changes that affect UM prior authorization processes. Compliance with HIPAA regulations and maintaining of patient confidentiality. Cultural and Linguistics training required annually. Other duties as assigned.