Job details
Job type full-time
Full job description
*shift: monday - friday 8:30 am - 5:30 pm hawaii time*
Responsible for reviewing and determining which pending authorization requests need attention and providing the necessary outreach and assistance to the requesting providersPerforms outreach and motivation to providers to ensure their full engagement during the initial prior authorization processActs as liaison between providers, internal departments and specific accounts, clients, and claims department.
Reviews proactively, non-finalized authorization requests and works with providers to obtain information needed for a successful determination.
Observes and tracks authorization problem trends due to a lack of complete clinical information received in the initial request and works directly with the provider to educate and motivate them to resolve issues.
Review and analyzes denied claims to reduce the number of appeals that are overturned due to information that was provided in the initial review.
Motivates external stakeholders for successful participation and engagement in the review process .
Resolves cases in queue due to member eligibility issues, referring provider verification or request, imaging provider verification, redirection, and retro reviews.
Assists with authorization problem resolution through research and facilitating the resolution of the problem in a timely fashion.
Processes, forwards, trends, and maintains records of authorization issues.
Acts as a troubleshooter to resolve problems among internal departments.
Handles special requests from customers requiring manual workarounds or specials projects.
Investigates written or verbal complaints involving authorizations, and resolves complex issues with customers and p roviders.
Assists specific accounts who have special processes.
Assists with user acceptance testing (uat).
Other job requirements
Responsibilities
Demonstrated ability in the following areas: problem solving, meeting deadlines, showing initiative, and following-through on deliverables and commitments.
Excellent written and verbal communication skills.
Knowledge of how prior authorizations processes work between provider offices and insurance companies.
Understanding of health care appeals.
General job information
Title
Provider engagement associate
Grade
18
Work experience
Claims, customer service, health plans
Education
Bachelors, ged (required), high school (required)
License and certifications - required
License and certifications - preferred
Magellan health, incIs proud to be an equal opportunity employer and a tobacco-free workplaceEoe/m/f/vet/disabled.
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their
Position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
