- Evaluate and process prior authorization requests based on clinical guidelines such as Medicare, Medicaid/Medi-Cal criteria, MCG, or health plan-specific guidelines.
- Assess medical necessity and the appropriateness of requested services using clinical expertise.
- Verify patient eligibility, benefits, and coverage details.
- Act as a liaison between healthcare providers, patients, and health plans to facilitate the authorization process.
- Communicate authorization decisions to providers and patients promptly.
- Provide detailed explanations for denials or alternative solutions and collaborate with Medical Directors on adverse determinations.
- Accurately document all authorization activities in electronic medical records (EMR) or authorization systems.
- Maintain compliance with federal, state, and health plan regulations.
- Stay updated on policy and clinical criteria changes.
- Identify trends or recurring issues in authorization denials and recommend process improvements.
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