Authorization Specialist/ UM Trainer

Overview

To process TARs for selected services using specific procedures and protocol and to provide administrative assistance to UM Coordinators and Leadership staff as assigned. Serves as Systems Trainer for all new hires and provides ongoing education for all HS/UM staff.

Responsibilities

• Prepares and maintains up-to-date training and educational materials for new and existing staff.
• Provides hands-on training during new hire orientation.
• Collaborates in the on-going trainings for staff education of latest department changes and updates, which includes but is not limited to NCQA standards, Whole Child Model and Essette. As well as, develop and distribute supporting material
• Works closely with UM leadership to produce staff enhancement trainings, which includes development of the agenda, preparing materials and handouts, presenting the training in conjunction with leadership presenters.
• Provides training not only to the designated department HS/UM but also HS/CC and internal PHC’s departments that require support and knowledge of UM’s program and TAR process.
• Monitors and has full proprietorship of the UM Departments Help Desk, which includes assessing inquires, and either resolving or escalating to appropriate staff as needed
• Supports the successful implementation of the UM Department’s software systems and online services, proceeding the participation of a testing environment.
• Processes Treatment Authorization Requests (TARs) pertaining to wheelchairs, diabetic shoes, nebulizers, dialysis, and Hospice services, etc.
• Assists in determining appropriateness, quality and medical necessity for all specialty related medical equipment for pediatrics open to Whole Child Model, and necessity of DME for children enrolled with a County MTU Clinic.
• Works with appropriate consultants to facilitate the need for an in-home assessment to determine the medical necessity of DME equipment.
• Assists network providers and other departments with issues concerning TARs.
• Acts as a resource regarding UM department computer programs and special projects upon request.
• Verifies member’s eligibility and designated program benefits.
• Elicits medical information from provider, consulting with HS/UM clinical staff as appropriate.
• Monitors consultant’s turnaround time and initiates follow-up as necessary.
• Prepares Medical Director work sheet for review by Chief Medical Officer (CMO) or physician designee as appropriate.
• If not approved by consultant, reassigns TAR to UM Clinical Coordinator for processing.
• Provides overflow support to both Data Coordinators and Nurse Coordinators.
• Participates in special projects and assignments as required.
• Assists in the refinement/improvement of the UM Department by participating in continuous process improvement endeavors.
• Other duties as assigned.
  
  

Qualifications

Education and Experience

Certified Medical Assistant or minimum one (1) year experience in the medical/clerical field; or equivalent combination of education and experience. General knowledge of managed care with emphasis in UM preferred.

Special Skills, Licenses and Certifications

Ability to work within an interdisciplinary team structure and function in a fast-paced environment while managing multiple priorities and meeting deadlines. Strong organizational skills required. Effective telephone and computer data entry skills required. Ability to access data and information using automated systems. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.

Performance Based Competencies

Excellent written and verbal communication skills. Ability to follow established procedures and protocol. Ability to communicate effectively with coworkers, physicians, and health care providers.

Work Environment And Physical Demands

Daily use of telephone and computer for most of the day. Cubicle work station. Ability to use a computer keyboard. Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.
  
  

HIRING RANGE:

$34.79 - $43.48

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.