Job Description

The Prior Authorization Lead is the subject matter expert of the prior authorization process and is responsible for being the “first line” resource for prior authorization staff. This includes accurately answering questions regarding procedures, training, and processes to assure compliance with HPN policies and procedures. The Prior Authorization Lead assists the Prior Authorization Supervisor with daily management of prior authorization staff, auditing functions, and assuring that all staff provides a level of patient care that meets or exceeds the organization’s expectations.

Essential Duties and Responsibilities include the following:

• Assist with monitoring of prior auth process to assure patient care standards are met by all prior authorization staff.
• Perform all duties of coordinator specialist.
• Act as a subject matter expert for prior authorization.
• Primary interface with assigned campus administrators and medical directors on issues impacting prior authorization.
• Monitors inventory, work load and compliance.
• Address issues and work with supervisors to rebalance workloads to maintain regulatory compliance and service levels.
• Understand all aspects of the functionality of Access Express with respect to prior authorization and the customer service case modules.
• Complete assigned tasks accurately and within specified time limits.
• Handle employee referrals.
• Maintain smooth working relations with co-workers and supervisors. Be a “Team Player”
• Understand all Regal Medical Management policies and procedures to help create and maintain job aids that are consistent with these policies.
• Identify gaps in staff training and schedule ongoing training sessions for established staff to review processes with the department trainer.
• If needed, assist the prior auth trainer to train new employees to rapidly learn the Organizations principles of Medical Management and to facilitate the right care at the right time in the right setting.
• If needed, assist with auditing new hires during their training period to verify that all new skills learned are executed properly and within specifications.
• Speak clearly, concisely and tactfully on all subjects related to Medical Management.
• Anticipate our provider’s needs: Understand their wants and needs, listen for cues and identify how to respond and what level of intervention they need.
• Return phone calls to providers and follow up with requests in a timely fashion.
• Work in collaboration with the clinical coordinator team, Supervisor, Manager Sr Manager and Regional Medical Directors and Network Managers to assist with daily operations, assuring a level of referral processing that meets or exceeds the organization’s expectation.
• Recognize when an error has been made and immediately report it to the appropriate Supervisor or Manager. When an error is recognized, educate the team member who made the error.
• Maintain quality monitors as assigned by Sr Manager.
• Maintain quality monitors as assigned by Supervisor.
• Treat co-workers and customers with patience and respect.
• Assist other staff and support the team approach.
• Participate in the efficient, effective, and responsible use of resources such as supplies and equipment.
• Communicate appropriately and clearly to management, co-workers, and physicians.
• Arrive to work on time. Consistently be at work. Display flexibility regarding lunches, breaks and work hours.
• Willingness to work overtime when requested.
• All other duties as directed by management.

The pay range for this position at commencement of employment is expected to be between $30 - $32 per hour; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.

Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

Full Time Position Benefits:

The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.

Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.

Health and Wellness:

• Employer-paid comprehensive medical, pharmacy, and dental for employees
• Vision insurance
• Zero co-payments for employed physician office visits
• Flexible Spending Account (FSA)
• Employer-Paid Life Insurance
• Employee Assistance Program (EAP)
• Behavioral Health Services

Savings and Retirement:

• 401k Retirement Savings Plan
• Income Protection Insurance

Other Benefits:

• Vacation Time
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• Tuition Reimbursement
• License Renewal CEU Cost Reimbursement Program
• Business-casual working environment
• Sick days
• Paid holidays
• Mileage

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.

Qualifications

Education and/or Experience:

• High school graduate required; Associates in Arts degree or higher preferred.
• 3 years of experience in prior authorization, claims or related field required.
• Knowledge of Healthcare and Managed Care required.
• Is an expert at the Prior Authorization process.
• Proficient with turnaround time compliance in all aspects of the PA Process.
• Typing 60 word per minutes with accuracy.
• Knowledge of computers, faxes, printers and all other equipment.
• Experience with prior authorization process required.
• Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point).
• Ability to deal with responsibility with confidential matters.
• Ability to work in a multi-task, high energy environment.
• Ability to assist staff with completion of authorization.
• Ability to prioritize.
• Ability to monitor reports for inaccuracies and training opportunities.
• Ability to be proactive and initiate processes with little or no supervision.
• Understanding of how other departments impact or are impacted by Prior Auth.
• Ability to meet deadlines and ensure regulatory compliance.
• Ability to communicate appropriately and clearly with management, co-workers and physicians.
• Must possess strong organizational skills and be detail oriented.