Clinical Pre-Authorization Rep - Active RN, LVN License Required

Description

Spanish Bilingual Required

JOB SUMMARY

Responsible for a wide range of duties in support of CAS departmental efficiencies which may include but not limited to verification of benefits, obtaining authorization requirements, and authorization request submissions. Collaborates with CAS department leaders in operational and quality excellence.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

• Support clinical pre-authorization services team as follows:
  • Verify benefits and determine authorization requirements.
  • Submits requests for authorizations for simple procedures as determine by leadership.
  • Triage accounts to identify complex clinical requirement cases and/or escalate any issues to clinician for
    • Peer to peer and/or denials
    • Complex cases needing authorization i.e. surgery/wound care/chemo/complex RAD for medical necessity clinical pre-authorization.
• Customer Service – interaction with clients and Patient access staff. Facilitate / cooperate/collaborate on facilitating authorization process to include but not limited to requesting clarification on orders/requesting clinical/follow up on pending requests
• Performs the following activities to support the effective operation of the organization’s quality management system. A minimum of 2.5 % of time is spent carrying out the following responsibilities: Participation in quality control audit process; participation in department projects and activities to improve overall Conifer and client scorecard metrics. Provides feedback regarding improvement opportunities for workflow &/or procedures; and the contributes to successful implementation of all the above.
• Demonstrates proficiency in the use of multiple electronic tools required by both Conifer and its clients.
• Other duties as assigned.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Minimum typing skills of 35 wpm
• Demonstrated working knowledge of software/system/equipment
• Knowledge of function and relationships within a hospital / physician office environment preferred
• Advance customer service skills and experience
• Ability to work in a fast paced environment
• Ability to receive and express detailed information through oral and written communications
• Skill in Medical Terminology required
• Advanced understanding of third party payer requirements preferred
• Advanced understanding of compliance standards preferred
• High achievement in productivity
• Builds and maintains collaborative relationships with both internal and external clients that lead to more effective communication and a higher level of productivity and accuracy

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience preferred to perform the job.

• Graduate from accredited LVN or RN program with active licensure

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must be able to sit at computer terminal for extended periods of time
• Occasionally lift/carry items weighing up to 25 lbs.
• Frequent prolonged standing, sitting, and walking

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Characteristic of typical Call Center environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.

OTHER

• Must be available to work hours and days as needed (including weekends and holidays) based on departmental/system demands
• Resolves and as applicable escalates Physician's office and client issues
• May experience extreme case volumes and uncooperative parties

FINANCIAL RESPONSIBILITY (Specify Revenue/Budget/Expense): N/A SUPERVISORY RESPONSIBILITIES: N/A

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Minimum typing skills of 35 wpm
• Demonstrated working knowledge of software/system/equipment
• Knowledge of function and relationships within a hospital / physician office environment preferred
• Advance customer service skills and experience
• Ability to work in a fast paced environment
• Ability to receive and express detailed information through oral and written communications
• Skill in Medical Terminology required
• Advanced understanding of third party payer requirements preferred
• Advanced understanding of compliance standards preferred
• High achievement in productivity
• Builds and maintains collaborative relationships with both internal and external clients that lead to more effective communication and a higher level of productivity and accuracy

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience preferred to perform the job.

• High School Diploma or GED required
• 2-4 years experience in medical facility, health insurance, or related area
• Some college coursework is preferred

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must be able to sit at computer terminal for extended periods of time
• Occasionally lift/carry items weighing up to 25 lbs.
• Frequent prolonged standing, sitting, and walking

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Characteristic of typical Call Center environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.
• Resolves and as applicable escalates Physician's office and client issues
• May experience extreme case volumes and uncooperative parties

OTHER

• Must be available to work hours and days as needed (including weekends and holidays) based on departmental/system demands
• Resolves and as applicable escalates Physician's office and client issues
• May experience extreme case volumes and uncooperative parties

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities, and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost, and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!