BusinessOperations – Authorization Specialist II

Job Description: Position Purpose:
Acts as a resource and supports the prior authorization request process to ensure that all authorization requests are addressed properly in the contractual timeline. Supports utilization management team to document authorization requests and obtain accurate and timely documentation for services related to the members healthcare eligibility and access.

Education/Experience:
Requires a High School diploma or GED
Requires 1 – 2 years of related experience.

Knowledge of medical terminology and insurance preferred.Aids the utilization management team and maintains ongoing tracking and appropriate documentation on authorizations and referrals in accordance with policies and guidelines

Supports the authorization review process by researching and documenting necessary medical information such as history, diagnosis, and prognosis based on the referral to the clinical reviewer for determination

Verifies member insurance coverage and/or service/benefit eligibility via system tools and aligns authorization with the guidelines to ensure a timely adjudication for payment

Performs data entry to maintain and update various authorization requests into utilization management system

Supports and processes authorization requests for services in accordance with the insurance prior authorization list and routes to the appropriate clinical reviewer

Remains up-to-date on healthcare, authorization processes, policies and procedures
Performs other duties as assigned

Complies with all policies and standards
Comments for Vendors: Candidates can be sourced outside of IL as long as in CST.