Medical Authorization Assistant

Job Summary

The Medical Authorization Assistant provides office and referral management support services; assists the inpatient Case Managers in obtaining medical records, documenting all case information in the system, performing data entry into appropriate databases for monitoring and tracking, and following up on phone calls as directed by the Case Managers. The incumbent serves as the contact between members, physicians, facilities, providers, and CalOptima staff. The incumbent is responsible for processing the intake information and assisting with authorization functions. May also perform office support functions as required.

Position Responsibilities

• Receives inpatient requests via fax, phone, or electronically; enters data of new case information into the medical management system.
  
• Creates inpatient events based on facility face sheets and/or clinical received.
  
• Verifies member eligibility.
  
• Collects additional information from CalOptima members and/or providers/facilities to complete prospective, concurrent, or retrospective inpatient service reviews.
  
• Authorizes requested services according to CalOptima s Concurrent Review Team guidelines. Contacts the health networks and/or CalOptima Customer Service regarding health network enrollments.
  
• Assists the inpatient Case Manager in gathering medical records, obtaining appropriate coding for diagnosis and procedures, discharge dates, dispositions, and conducts follow up phone calls per concurrent review team standards.
  
• Documents all contacts and case information in the system using the standard charting format.
  
• Enters data into the appropriate databases for monitoring and tracking, trending of inpatient events, and other relevant databases as needed.
  
• Completes discharge follow up duties as assigned.
  
• Other projects and duties as assigned.
  

Possesses the Ability To:

• Utilize Concurrent Review protocols to determine when to refer matters to licensed staff.
  
• Establish and maintain effective working relationships with CalOptima leadership and staff.
  
• Communicate clearly and concisely, both verbally and in writing, as well as with individuals from diverse backgrounds.
  
• Utilize computers, keyboarding, and appropriate software (e.g., Microsoft Office applications and job specific applications) to produce correspondence, charts, spreadsheet, and/or other information applicable to the position assignment.
  

Requirements

Experience & Education:

• High school diploma or equivalent required.
  
• 2 years of experience in a Healthcare or Managed Care setting required.
  

Preferred Qualifications:

• Previous Medical Billing and Coding experience preferred.
  
• Certified Medical Assistant (CMA) certification preferred.
  
• Concurrent Review and Utilization Management experience preferred.
  
• Bilingual in English and in one of CalOptimas defined threshold language (Spanish, Vietnamese, Farsi, Arabic, Korean, and Chinese) is preferred.
  

Knowledge of:

• Medical terminology.
  
• ICD-10 and CPT coding.
  
• Medi-Cal and Medicare benefits and regulations.
  

Benefits

At Sunshine Enterprise USA LLC, we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits:

Competitive pay & weekly paychecks

Health, dental, vision, and life insurance

401(k) savings plan

Awards and recognition programs

Benefit eligibility is dependent on employment status.

Sunshine Enterprise USA is an Equal Opportunity Employer Minorities, Females, Veterans and Disabled Persons