Prior Authorization Representative

Job Description

Description: Supports comprehensive coordination of medical services including intake, screening and referrals to Aetna Medical Services Programs. Promotes/supports quality effectiveness of Healthcare Services.

66082

Fundamental Components: Performs intake of calls from members or providers regarding services via telephone, fax, EDI.Utilizes eTUMS and other Aetna system to build, research and enter member information.Screens requests for appropriate referral to medical services staff.Approve services that do not require a medical review in accordance with the benefit plan.Performs non-medical research including eligibility verification, COB, and benefits verification.Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., claim administrators, Plan Sponsors, and third party payers as well as member, family, and health care team members respectively) Protects the confidentiality of member information and adheres to company policies regarding confidentiality Communicate with Aetna Case Managers, when processing transactions for members active in this ProgramSupports the administration of the precertification process in compliance with various laws and regulations, URAQ and/or NCQA standards, where applicable, while adhering to company policy and procedures.Places outbound calls to providers under the direction of Medical Management Nurses to obtain clinical information for approval of medical authorizations. Uses Aetna Systems such as QNXT, ProFAX, ProPAT, and Milliman Criteria. Communicates with Aetna Nurses and Medical Directors, when processing transactions for members active in this Program. Sedentary work involving significant periods of sitting, talking, hearing and keying. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor. Working environment includes typical office conditions. Background Experience: 2-4 years experience as a medical assistant, office assistant or other clinical experience. High School Diploma or G.E.D. Additional Job Information: Effective communication, telephonic and organization skills.Familiarity with basic medical terminology and concepts used in care management.Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members.Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word.Ability to effectively participate in a multi-disciplinary team including internal and external participants. Required Skills: General Business - Turning Data into Information, Service - Demonstrating Service Discipline, Service - Working Across Boundaries Desired Skills: General Business - Communicating for Impact, Service - Handling Service Challenges, Service - Providing Solutions to Constituent Needs Potential Telework Position: No Percent of Travel Required: 0 - 10% EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility: Benefit eligibility may vary by position. Candidate Privacy Information: Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.