- Run benefit eligibility checks and keep member eligibility status accurate and current.
- Manage medical prior authorization requests, renewals, and extensions across payers and specialty pharmacy partners.
- Prepare and submit prior authorization documentation, track approval status, and escalate stalled or denied authorizations.
- Follow up with provider offices on unsigned documents and orders; process referrals, faxes, and clinical documents.
- Coordinate clinical staffing with staffing agencies and medication shipping with pharmacy partners.
- Answer and route inbound calls, document call details, and follow through on action items.
- Collect, organize, and store member records and clinical documentation in accordance with internal standards and HIPAA requirements.
- Design, document, and improve operational workflows.
Process improvementEHR