Medicaid Prior Authorization Specialist I Details

Medicaid Prior Authorization Specialist I

Yukon-Kuskokwim Health Corporation - Bethel, AK

Employment Type : Full-Time

Your passion is in what you do, the care you provide, and the dedication with which you serve. It is the same commitment with which our people live their lives, and in turn, share their culture.

With Yukon-Kuskokwim Health Corporation in Bethel, Alaska, you’ll serve the over 50 rural communities in the Yukon Delta Region who come to us for care. You’ll grow your skills and expertise in a clinically challenging environment, and experience a community environment within a community that will embrace you as one of their own.

Serving the people of Southwestern Alaska, the Yukon-Kuskokwim Hospital is a 50-bed general acute care medical facility. Fully accredited by The Joint Commission, services include adult med/surg, pediatrics, obstetrics, emergency room, as well as outpatient family medicine clinics, pharmacy, lab, and imaging.

Position Summary:

Medicaid Prior Authorization Specialist I under normal supervision, assists in providing transportation/logistical assistance to Alaska Medicaid Recipients traveling to and from the Yukon Kuskokwim Health Corporation (YKHC) service area by determining if the burden of medical necessity has been met by documenting these findings in detail through the appropriate computer systems.

Level 1 employees perform work under close supervision, may only perform simple or routine aspects of the position, and generally require a good deal of instruction and/or training. Senior lead employees perform high level, complex and responsible tasks within this position and generally work with minimum supervision and follow-up from their supervisor.

The following duties are intended to provide a representative summary of the major duties and responsibilities and ARE NOT intended to serve as a comprehensive list of all duties listed and may be required to perform additional, position-specific duties.

REPRESENTATIVE DUTIES

For Medicaid eligible patients and/or escorts, works with clinical providers to determine if medical necessity has been met prior to transportation services. Also, serves as the liaison between the YKHC and the State of Alaska regarding Medicaid Transportation Services. Gathers all information requested by the Alaska State Medicaid Representative by utilizing various computer systems and by communicating to all parties involved so that all prior authorization requests can be handled in a timely manner.

Work collaboratively with patient on eligibility issues. Must be knowledgeable about when to refer patient to the YKHC Medicaid Enrollment department and/or Alaska Division of Public Assistance (DPA) to move authorization along in an expeditious manner.

This position will draw upon experience and general knowledge; will review documentation or contacts the provider or requestor when necessary in order to prove medical necessity for the authorization.

This position will also ensure that there is appropriate 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.

This position will coordinate with or will assume the function of Prior Authorization, Provider Inquiry and Claims Resolution units to ensure provider/claims resolution.

• Answer provider inquires in writing and verbally
• Submit claims, adjustments, voids, etc., electronically and in paper formats
• Perform and/or evaluate Prior Authorization on-line updates ensuring that notes are accurate and demonstrate the medical necessity for the authorization approval and/or denial.
• Perform and/or evaluate, and/or resolve process claims.

Maintain a database of information reflecting problems found and actions taken.

Analyze findings and advise supervisor of significant system or provider problems/concerns.

Work closely with State entities involved with provider claims.

Work closely with YKHC office assistants/ health aides and providers, ANTHC/YKHC Medicaid Travel Office’s and the State of Alaska to coordinate the customers lodging and travel needs.

May be required to work outside the traditional work schedule. Performs other duties as assigned.

KNOWLEDGE and SKILLS

• Knowledge of customer service concepts and practice.
• Knowledge of the Privacy Act of 1974 and HIPAA Privacy Rule Act of 1966.
• 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 grammar, spelling, sentence structure and effective business letter writing.
• Skill in establishing and maintaining cooperative working relationships with others.
• Skill in operating a personal computer utilizing a variety of software applications and be able to retain multiple passwords.

Position Qualifications:

• High school diploma or equivalent. Computer literacy required.
• Non-supervisory – Two (2) years of clerical AND customer service experience. An equivalent combination of relevant education and/or training may be substituted for experience.
• Basic computer/excel skills.
• 10 touch experience preferred.
• Must take the State of Alaska HIPAA test.
• Copiers, print, fax machines, and multi-line telephones. Be able to access multiple computer programs simultaneously.
• Be able to work in a fast paced office independently. Be able to multi-task between different computer programs, retaining different passwords as needed.

Benefits Include:

• Generous PTO – beginning at 4.5 weeks
• Ten paid holidays
• Comprehensive healthcare coverage
• Life and Disability Insurance
• Flexible Spending Account
• Retirement plans
• Employee Wellness Center