Prior Authorization Specialist II

Position Summary

Under supervision, screen patient eligibility and assess clinical information, referred patients to determine eligibility for State of Alaska Medicaid Travel Benefits. Assist the patient, clinic and service unit with successful evaluation and submission for patient travel benefits.

Responsibilities

• Conducts clinical evaluations of documentation provided by the patient, ANMC, and healthcare entities to determine eligibility for patient travel benefits under the rules and regulations of the Alaska State Medicaid Program.
• Serves as the liaison between the patient, ANMC and the State of Alaska regarding Medicaid Transportation Services to prove medical necessity for a Medicaid Travel Authorization.
• Must be able to communicate effectively with patients and various healthcare professional providing updates on authorization information and required documents needed to be sent to the State of Alaska.
• Gathers all information requested by the Alaska State Medicaid Representative by utilizing various computer systems and by communicating with ANMC or Tribal Health Partner RN Case Managers.
• Informs customers about other services and resources that are available to them.
• Works collaboratively with other members of the team and departments, as well as outside agencies, to ensure the State of Alaska Rules and Regulations are being met while also serving as an advocate for the patient and referring provider.
• Will determine continued or amended eligibility in real time with all tribal travel agencies and relative accommodations.
• Ensures that there is accurate documentation to prove the medical necessity of the travel authorization. All submitted authorizations should reflect the correct CPT and diagnosis codes. All authorizations numbers should be reflective of the dates authorized and should correspond to the services authorized.
• Coordinates with or assumes the function of Prior Authorization, Provider Inquiry, and Claims Resolution units to ensure provider/claims resolution.
• Analyzes findings and advise supervisor of significant system or provider problems/concerns, work aged or other associated production reports as well as all State entities involved with provider claims.
• Performs other duties as assigned or required.

Knowledge and Skills

• Knowledge of Alaska Tribal Health System, ANTHC, and Alaska Native culture(s).
• Knowledge of alternative health resources.
• Knowledge of customer service concepts and practice.
• Knowledge of basic medical terminology, abbreviations, ICD 10 Coding and clinic systems.
• Knowledge of the Privacy Act of 1974 and HIPAA Privacy Rule Act of 1966.
• Knowledge of state, federal, and tribal health care programs.
• Knowledge of state, federal and public/private insurance, including Medicaid/Medicare.
• Skill in accuracy with data entry and the ability to make detailed notes.
• Skill in working independently or as a team member.
• Skill in dealing with distressed customers.
• Skill in grammar, spelling, sentence structure and effective business letter writing.
• Skill in operating office equipment, including copiers and fax machines.
• Skill in interpreting state, federal, and public/private insurance financing.
• Skill in oral and written communication.
• Skill in managing multiple priorities and tasks concurrently and meeting deadlines.
• Skill in establishing and maintaining cooperative working relationships with others.
• Skill in operating a personal computer utilizing a variety of applications.

Minimum Qualifications

• High school diploma or GED equivalent.
• Non-supervisory – Two (2) years of Alaska Medicaid experience AND two (2) years of customer centric OR one (1) year working for ANMC Travel Management Office as a Prior Authorization Specialist I.
• An equivalent combination of relevant education and/or training may be substituted for experience.
• Must have successfully mastered Two (2) of the following areas of PA Duties:
  • Alaska Medicaid Rules and Regulations
  • Tribal Travel vs Medicaid eligible travel
  • Navigate and document in Alaska Medicaid, State and ANMC software applications
  • Eligibility determination and appropriate screening

Preferred Experience

• Basic computer, software applications and data entry experience.

Additional Requirements

• Will need to be able to work weekend shifts and holidays.