Clinical Services Authorization Specialist

2 weeks ago

Atlanta, Georgia, United States US Tech Solutions Full time

Job Title: Clinical Services Authorization Specialist

Location: Fully remote

Duration: 10 months contract

Job Overview:

The Clinical Services Authorization Specialist will play a vital role in supporting various operational tasks, including but not limited to: making outbound calls, reviewing and processing authorization requests received through electronic and traditional methods, and managing inquiries through departmental communication channels. This position will also involve additional responsibilities as directed by the management team.

Collaboration with healthcare providers is essential to facilitate the processing of prior authorization (PA) and drug benefit exception requests across multiple client accounts and service lines, adhering to regulatory guidelines. The specialist will utilize information from diverse sources to apply the established criteria for authorization requests. This role requires proactive outreach via phone to healthcare providers to gather necessary information for processing coverage requests and ensuring all actions are completed to finalize cases. The specialist will also be responsible for identifying and rectifying any discrepancies encountered during the process. Phone support is a critical component for initiating and resolving coverage inquiries. Issues that require further attention will be escalated to the appropriate teams as necessary. Compliance with regulatory standards is paramount at all times.

Key Responsibilities:

  • Participate in training and work remotely.
  • Utilize various software platforms to conduct reviews of Medicare appeals cases.
  • Meet or exceed mandated timelines set by regulatory bodies.
  • Adhere to productivity and quality benchmarks.
  • Communicate resolutions to beneficiaries or providers through direct interaction and professional correspondence.
  • Maintain up-to-date knowledge of relevant Medicare guidance and regulations.

Required Experience:

  • A minimum of two years in a business environment, focusing on problem-solving, professional writing, quality enhancement, and customer service.
  • At least six months of experience in a remote work setting.
  • Experience in the pharmaceutical or pharmacy benefit management sector is highly desirable.

Essential Qualifications:

  • Ability to work independently while recognizing when to seek assistance.
  • Technical proficiency in troubleshooting and effectively communicating outcomes to leadership or IT teams.
  • Strong verbal communication skills with the ability to manage multiple software applications.
  • Results-oriented and accountable.
  • Critical thinking and problem-solving capabilities.
  • Open to constructive feedback and adaptable to change.
  • Effective planning, prioritization, and time management skills.
  • Ability to thrive in a fast-paced, regulated environment.
  • Proficient in navigating various computer applications.
  • Skilled in using keyboard and mouse, with the ability to operate dual monitors.
  • Typing speed of over 30 words per minute.

Skills:

  • Prior Authorization expertise.
  • Knowledge of Medicare and Medicaid systems.
  • Experience in call handling.
  • Familiarity with Pharmacy Benefit Management (PBM) processes.

Education:

High School diploma or equivalent required.

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