The Medical Authorization Assistant (MA) provides office and referral management services. The MA serves as a contact between members, physicians, providers and CalOptima staff, processing initial intake of information, assisting with authorization functions and gathering information. Position is responsible for reviewing and processing requests for authorization and notification of medical services from health professionals, clinical facilities and ancillary providers. The incumbent is responsible for tasks/functions related to CalOptima's prior authorization and referral process. Responsible for applying CalOptima's medical criteria and policies/procedures to authorization or referral requests from medical professionals, clinical facilities and ancillary providers. Directly interact with provider callers, acting as a resource for their needs. The position operates under the direction of the licensed Nurse.
Receives referral request via fax, phone, or electronically and data enters new service request information into the authorization system.
Collects additional information from CalOptima members and/or providers to complete referral information.
Authorizes requested services according to CalOptima's authorization guidelines, performing data entry into the authorization system, and verifying eligibility.
Contacts the Health Networks and/or CalOptima Customer Service regarding health network enrollments.
Assists the authorization Nurse in gathering medical records, obtaining appropriate coding for diagnosis and procedures, and follow up on phone calls as directed by the authorization Nurse.
Documents all contacts and case information in the system, using the standard charting format.
Performs data entry into the appropriate databases for monitoring and tracking, trending of events and other relevant databases as needed.
Other projects and duties as assigned.
Communicate and obtain relevant needed data from members, providers, etc., to record and summarize findings.
Communicate with individuals from diverse backgrounds.
Develop and maintain effective working relationships with all levels of staff, other programs, community agencies, providers and members.
Effectively utilize computer and appropriate software (Microsoft Office Suite) to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Utilize prior authorization protocols to determine when to refer matters to a licensed staff person.
Required Experience Experience & Education:
High school graduate or equivalent.
2 years of related experience that would provide the knowledge and abilities listed.
Bilingual in English and in one of CalOptima's defined threshold language is preferred.
Current ICD 10- CPT, and HCPCS Coding continual updates to knowledge base regarding the codes.
Medi-Cal and Medicare benefits and regulations.
Job Location Orange, California, United States Position Type Full-Time/Regular