PURPOSE OF THE POSITION:
Provide timely management of incoming fax requests within regulatory required timeframes, towards achievement of Affinity's Medical Management goals and objectives.
ESSENTIAL FUNCTIONS: Authorization Queue Management
1. Processes and triages all incoming faxed requests and Altruista events to assigned Nurses and Coordinators for requests for clinical information and medical necessity determinations
2. appropriately to maintain compliant tum-around times with decision making.
3. Monitors aging of authorizations and priority of services to support adherence to timeframes and provider satisfaction completed immediately.
4. Monitors system letter report for aging of letter generation to ensure that letters have been sent out within the 24 hour compliance period.
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5. Communicates effectively with Supervisor- Medical Management Precertification and other departmental leaders to effectively problem-solve when activity spikes or other outliers threaten compliance with Affinity departmental and regulatory compliance.
6. Actively participates in departmental and interdepartmental meetings, as directed, to support effective and efficient management of authorization requests.
Precertification of Authorization Requests:
1. authorizations of medical services. Applies Milliman Care Guidelines TM to determine medical necessity of requests for service.
2. Obtains clinical information to support Affinity Health Plan policies and regulatory requirements.
3. Evaluates the Medical Necessity of referral requests based upon established authorization rules.
4. Identifies sentinel data which indicates potential quality of care issues for referral to Quality Management for review.
5. Enters all authorization information and accompanying clinical documentation in Affinity's system of record and generates appropriate correspondence relating to authorization activity to the provider and/or the member.
6. Directs all out-of-network requests in-plan when possible.
7. Acts as a resource to the Customer Service staff by responding to benefits or authorization questions.
8. Refers cases for nurse review when appropriate to determine if medical necessity criteria have been met.
Other:
1. Coordinate complex, high risk Member cases, including emergent and elective hospital admissions, transplant services, outpatient procedures and other service requests in conjunction with a team of licensed health care professionals.
2. Demonstrate proficiency with the principles and methodologies of process improvement. Apply these in the execution of responsibilities in support of a process focused approach.
3. Performs other duties as necessary or assigned.
QUALIFICATIONS:
- High School diploma or the equivalent; Associates degree in a related field preferred
- Minimum of two (2) years of care coordination experience, which included Medicaid or Medicare members
- Managed care experience preferred, or experience working in collaboration with Health Plans regarding discharge planning and coordination of service requests.
- Excellent verbal and written communication skills to ensure the concise, accurate and timely communication of information.
- Excellent customer service skills as demonstrated by a pleasant telephone manner and by courtesy, accuracy and follow-through.
- Good keyboarding skills required; proficiency with Microsoft Office applications.
- Ability to prioritize multiple tasks as demonstrated by the timely and successful completion of assigned tasks.