- Evaluate and process prior authorization requests using clinical guidelines, including Medicare, Medicaid/Medi-Cal criteria, MCG, or health plan-specific guidelines.
- Assess medical necessity and the appropriateness of requested services.
- Verify patient eligibility, benefits, and coverage details.
- Coordinate authorization activity with healthcare providers, patients, and health plans.
- Communicate authorization decisions promptly and explain denials or alternative solutions.
- Collaborate with Medical Directors on adverse determinations and ensure notices meet regulatory requirements.
- Document authorization activities in electronic medical records or authorization systems.
- Maintain compliance with federal, state, and health plan regulations and stay updated on policy and clinical criteria changes.
- Identify trends in authorization denials and recommend process improvements.
- Participate in team meetings, training sessions, and audits.
Microsoft Office