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Job Description
Primary City/State:
Phoenix, Arizona
Department Name:
Prior Authorization
Work Shift:
Day
Job Category:
General Operations
The future is full of possibilities. At Banner Health, we’re excited about what the future holds for health care. That’s why we’re changing the industry to make the experience the best it can be. If you’re ready to change lives, we want to hear from you.
We are a team that values and appreciates one another and supports each other through all the challenges that come our way. Our medical management team is accredited through both URAC and NCQA.
Banner Health Network (BHN) is an accountable care organization that joins Arizona’s largest health care provider, Banner Health, and an extensive network of primary care and specialty physicians to provide the most comprehensive healthcare solutions for Maricopa County and parts of Pinal County. Through BHN, known nationally as an innovative leader in new health care models, insurance plans and physicians are coming together to work collaboratively to keep members in optimal health, while reducing costs.
POSITION SUMMARY
Under the direction of the NOA Senior Mgr., the primary purpose of this position is to process all Notices of Action (NOA) and Notices of Non-Medical Coverage (NOMNC) for services accurately and in a timely manner.
CORE FUNCTIONS
1. Reviews all UAHP denials for eligibility, expiration date, accuracy and completeness.
2. Writes all member information in AHCCCS/SNP approved NOA/NOMNC templates to meet regulatory requirements.
3. Enters all denials/partial denials/service reductions into the computer systems.
4. Performs other related duties, consistent with the goals and qualifications of this position.
5. Works cooperatively with both internal and external customers in assisting members and providers with referral related issues.
6. Call rotation for the health plan, as well as departmental call rotation for holidays.
7. Meets internal and external customer service expectations regarding duties and professionalism.
8. This position performs all related duties in a manner that is consistent with and in support of the organization’s mission, vision, values and goals.
9. This position works under supervision, prioritizing data from multiple sources to provide quality care and support. Incumbents work in a fast-paced, sometimes stressful environment with a strong focus on customer service. Interacts with staff at all levels throughout the organization.
MINIMUM QUALIFICATIONS
Current, unrestricted AZ LPN license permitting work in the State of Arizona. A minimum of three years’ experience in an acute care setting. At least two years of experience in prior authorization or utilization management, knowledge of insurance, managed care principles, and community facilities and resources.
Proficient on a computer (PC) with Microsoft Office Products. Ability to work with data bases/programs, such as IDX and ability to work independently, with analytical, problem solving, decision making, concurrent and retrospective data management skills are necessary. Working knowledge of medical terminology and coding (ICD-9, CPT-4) is required.
PREFERRED QUALIFICATIONS
Experience specific to ICU/Med. Surg. and knowledge of Arizona Health Care Cost Containment System (AHCCCS) and Centers for Medicare and Medicaid Services (CMS) regulations preferred. Knowledge of AHCCCS, CMS and regulatory requirements and working knowledge of clinical criteria such as Milliman Care Guidelines is preferred.
Additional related education and/or experience preferred.
