Position Summary:

The Prior Auth Specialist is responsible for assisting with the delivery of quality health care services. They must be proficient in all aspects of the prior auth process. They are responsible for supporting the clinician reviewers and medical directors as a resource for clarification and researching, complex member referral history for additional information needed in order to review the request based on medical necessity. They will monitor all their assigned referrals to ensure regulatory turnaround time compliance, assist with expediting finalization of referrals, and monitor requests that may require additional information prior to Regional Medical Director finalization. The Auth Specialist will work in collaboration with the department Prior Auth Assistants, Coordinators, Team Leads, Supervisor, Managers and Regional Medical Directors and Network Managers to assist with daily operations and assuring a level of referral processing that meets or exceeds the organization's expectation.

Essential Duties and Responsibilities include the following:

• Must be proficient in all aspects of the prior auth process.
• Perform all assistant and coordinator job functions.
• Able to solve complex prior authorization questions and issues.
• Effectively handle all incoming provider calls including the most challenging provider offices.
• Identified trends with provider offices and interfaces with those provider offices.
• Request Network Management training or on site visit to provider offices needing reinforcement.
• Identified issues that need to be escalated to a lead or supervisor.
• Identify opportunities for improvement and make recommendations for change.
• Understand the wants and needs of customers, listen for cues and identify how to respond and what level of intervention they need.
• Communicate effectively and interact with the provider group and health plans daily or as indicated regarding Prior Authorization issues.
• Return phone calls to providers and follow up with requests in a timely fashion.
• “First line” resource for the clinicians and Medical Directors for outpatient referral inquiries.
• Process request that are deferred and bring them to resolution.
• Responsible for supporting the clinician reviewers and medical directors as a resource for clarification and researching, complex member referral history for additional information needed in order to review the request based on medical necessity.
• Review each case with the established expectations for quality.
• Capture any leakage and provide feedback to the leadership team for additional training.
• Monitor all their assigned referrals to ensure regulatory turnaround time compliance, assist with expediting finalization of referrals, and monitor requests that may require additional information prior to Regional Medical Director finalization.
• Work in collaboration with the department Prior Auth Assistants, Coordinators, Team Leads, Supervisor, Managers and Regional Medical Directors and Network Managers to assist with daily operations, training, auditing functions, and assuring a level of referral processing that meets or exceeds the organization's expectation.
• Recognize when an error has been made and immediately reports to appropriate Lead, Supervisor or Manager.
• Maintain quality monitors as assigned by Supervisor.
• Complete assigned tasks accurately and within specified time limits.
• Treat co-workers and customers with patience and respect.
• Assist other staff and support the team approach.
• Participates in the efficient, effective, and responsible use of resources such as supplies and equipment.
• Communicate appropriately and clearly to management, co-workers, and physicians.
• Arrives 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 $25 - $27 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.

Education and/or Experience:

• High school graduate required; Associates degree or higher preferred.
• Minimum of 2+ years as a Prior Auth Coordinator.
• Proficient in principles of managed care.
• Typing 60 words per minutes with accuracy.
• Knowledge of computers, faxes, printers and all other equipment.
• 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 prioritize.
• Ability to meet deadlines and ensure regulatory compliance.
• Ability to communicate appropriately and clearly with management, co-workers and physicians.
• Ability to operate PC based software programs or data base management systems
• Experience with prior authorization process strongly preferred.
• Must possess strong organizational skills and be detail oriented.
• Proficient with turnaround time compliance in all aspects of the PA Process.
• Ability to deal with responsibility with confidential matters.