Job Description

Duties & Responsibilities:

85% - Medical Authorization

Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.

Receives inpatient requests via fax, phone, or electronically and enters data of new case information into the medical management system.

Creates inpatient events based on facility face sheets and/or clinical received.

Verifies member eligibility.

Collects additional information from CalOptima Health members and/or providers/facilities to complete prospective, concurrent, or retrospective inpatient service reviews.

Authorizes requested services according to CalOptima Health's Concurrent Review team guidelines.

Contacts the health networks and/or CalOptima Health Customer Service department regarding health network enrollments.

Assists the inpatient Medical Case Manager in gathering medical records, obtaining appropriate coding for diagnosis and procedures, discharge dates, dispositions, and conducts follow-up phone calls per concurrent review team standards.

10% - Administrative Support

Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.

Documents all contacts and case information in the system using the standard charting format.

Enters data into the appropriate databases for monitoring and tracking, trending of inpatient events, and other relevant databases as needed.

5% Completes other projects and duties as assigned.

Minimum Qualifications:

High School diploma or equivalent required.

2 years of experience in a health care or managed care setting required.

Preferred Qualifications:

Previous medical billing and coding experience.

Certified medical assistant (CMA) certification.

Concurrent review and utilization management experience.

Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).

Required Licensure / Certifications:

N/A

Knowledge & Abilities:

Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.

Work independently and exercise sound judgment.

Communicate clearly and concisely, both orally and in writing.

Work a flexible schedule; available to participate in evening and weekend events.

Organize, be analytical, problem-solve, and possess project management

Preferred Qualifications

Certified Medical Assistant (CMA) certification.

Experience working with the needs of seniors or persons with disabilities (SPD) in a customer/member service capacity.

Previous medical billing or coding experience.

Utilization management experience.

Bilingual in English and in one of defined threshold languages (Arabic, Chinese, Farsi, Korean, Spanish, Vietnamese).

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance.