Medical Authorization Specialist (MAS3CQCT)

Medical Authorization Specialist (MAS3/CQCT)

This recruitment will be used to fill multiple positions.

The Medical Authorization Specialist (Medical Assistance Specialist 3) provides expert consultative services to providers and clients within the prior authorization process helping ensure that requested procedures tests and medications meet evidence-based clinical guidelines. The position involves high-volume caseload work with an emphasis on accuracy timelines WA Administrative Codes (WACs) and ProviderOne systems. Fully-telework eligible and based in Olympia this role is a strong fit for someone with a background in health care office settings insurance claim processing or public assistance eligibility determination.

All HCA employees will apply an equity lens to their work which may include but is not limited to all analyses of core business and processes.

About the division:

The Clinical Quality and Care Transformation (CQCT) Division is responsible for designing and implementing clinical policy and conducting oversight and monitoring of clinically related activities. CQCT partners with tribes stakeholders providers plans delivery systems and others on state-wide clinical activities and issues. These clinical policies and operations include leading the state in care transformation and supporting HCA programs.

About the position:

This position supports the mission and vision as we work together to provide quality services that enhance our clients ability to obtain and access health care by providing expert consultative services to providers and clients. Prior authorization protects clients from unproven or risky procedures tests or medications that may be harmful and do not meet evidence-based guidelines of effective treatment.

Some of what you will do:

• Independently review analyze and process incoming complex medical and medical equipment prior authorization requests for validity and compliance with the Medicaid Provider Guides numbered memorandums and WACs. Apply complex policies state and federal rules and regulations.
• Correlates data obtained from sources outside the department to build history on specific clients.
• Evaluate individual complex authorization requests for appropriateness completeness compliance with established medical standards regulations and policies medical contraindications and medical necessity. When appropriate communicate with providers to obtain medical justification for the request.
• Communicate/educate providers to answer questions regarding prior authorization requests and program policy and/or criteria.
• Based on guidelines independently make approval decisions on complex prior authorization requests and/or route the request to the appropriate clinical staff.
• Determines allowed payment based on manufacturer information and WAC pricing and methodology.
• While processing requests maintain an acceptable office error rate of less than three percent.
• Independently resolve complex issues related to the multiple complex agency programs. This requires professional communication with providers clients and other HCA staff to resolve complex issues
• Notify clients and providers of decisions through clear and concise technical correspondence based on medical necessity of the service requested. Provide senior level consultative services to providers HCA staff and other state agency staff with respect to multiple agency programs. Maintain workflow for compliance.
• Establish and maintain cooperative and effective relationships with others and demonstrate effective problem-solving techniques when interacting with others
• Review analyze and process incoming Alien Emergency Medical (AEM) eligibility requests being submitted to CQCT for review and decisions. Ensure all documentation is received and accurate.
• Communicate across divisions and agency regarding documentation requirements and any questions needing to be problem-solved.
• Based on guidelines make approval decisions or refer to clinical review.
  

Required qualifications:

Qualifying candidates will meet one of the following criteria options:

Option 1:

Bachelors degree in business administration healthcare administration Health Information Management or a related field and one (1) year of experience working in a medical dental or other health care office setting making public assistance eligibility determinations; health insurance premiums/claims processing adjusting and investigation; or other medical premiums/claims related experience.

Option 2:

Associate degree or Completion of a Certificate of Medical Billing and Coding and three (3) years of experience working in a medical dental or other health care office setting making public assistance eligibility determinations; health insurance premiums/claims processing adjusting and investigation; or other medical premiums/claims related experience.

Option 3:

Five years of experience working in a medical dental or other health care office setting making public assistance eligibility determinations; health insurance premiums/claims processing adjusting and investigation; or other medical premiums/claims related experience.

Option 4:

One (1) year as a Medical Assistance Specialist 2 in State Government possessing the experience listed above.

Required competencies:

• The ability to take action to learn and grow.
• The ability to take action to meet the needs of others.
• Ability to handle high volumes of work.
• Ability to meet timelines.

Preferred qualifications:

• Knowledge of Washington Administrative Codes (WAC) related to prior authorization Agency administered programs and the Health Care Authority (HCA) Medicaid Provider Guides.
• Experience and knowledge in the Provider One system (MMIS).
• Ability to use multiple software applications (e.g. Microsoft Word Excel Access and Outlook).

How to apply:

Only candidates who reflect the minimum qualifications on their NEOGOV profile will be considered. Failure to follow the application instructions below may lead to disqualification. To apply for this position you will need to complete your profile which includes three professional references and attach in separate files:

• A cover letter that specifically addresses how you meet the qualifications for this position
• Current resume

To take advantage of veteran preference please do the following:

• Attach a copy of your DD214 (Member 4 long-form copy) NGB 22 or USDVA signed verification of service letter.
• Please black out any PII (personally identifiable information) data such as social security numbers. Include your name as it appears on your application in .

About HCA:

Functioning as both the states largest health care purchaser and its behavioral health authority the Washington State Health Care Authority (HCA) is a leader in ensuring Washington residents have the opportunity to be as healthy as possible.

There are three pillars of our work: Apple Health (Medicaid); the Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB) programs; and behavioral health and recovery. Under these pillars HCA purchases health care including behavioral health treatment for more than 2.7 million Washington residents and provides behavioral health prevention crisis and recovery supports to all Washington residents.

What we have to offer:

• Meaningful work with friendly co-workers who care about those we serveVoices of HCA
• A clear agency mission that drives our work and is person-centeredHCAs Mission Vision & Values
• A healthy work/life balance including alternative/flexible schedules and mobile work options.
• A great total compensation and benefit packageWA State Government Benefits
• A safe pleasant workplace in a convenient location with restaurants and shopping nearby.
• And free parking!

Notes:

This position is covered by the Washington Federation of State Employees (WFSE). Once the listed position(s) is(are) filled this recruitment announcement may also be used to fill additional position(s) for up to sixty (60) days.

Prior to a new hire a background check including criminal record history will be conducted. Information from the background check will not necessarily preclude employment.

HCA is an equal opportunity employer. We value the importance of creating an environment in which all employees can feel respected included and empowered to bring unique ideas to the agency. HCA has five employee resource groups (ERGs). ERGs are voluntary employee-led groups whose aim is to foster a diverse inclusive workplace aligned with HCAs mission.Our diversity and inclusion efforts include embracing different cultures backgrounds and viewpoints while fostering growth and advancement in the workplace. Studies have shown women racial and ethnic minorities and persons of disability are less likely to apply for jobs unless they feel they meet every qualification as described in a job description. Persons over 40 years of age disabled and Vietnam era veterans as well as people of all sexual orientations and gender identities are also encouraged to apply. If you have any questions about the required qualifications or how your experience relates to them please contact us at .Persons with disabilities needing assistance in the application process or those needing this job announcement in an alternative format may contact Lisa Fleming at or

The Washington State Health Care Authority (HCA) is an E-Verify employer. All applicants with a legal right to work in the United States are encouraged to apply.

E-Verify is a registered trademark of the U.S. Department of Homeland Security.

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