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Clinical Authorization Verification Specialist

SUMMARY:

It is the responsibility of the Clinical Authorization Verification Specialist to request authorization reference numbers for initial and reoccurring clients from Medicaid HMO for Targeted Case Management and Psychosocial Rehabilitation services and to help monitor the use of authorized units for the Case Management.

QUALIFICATION FOR POSITION:

  • Bachelors in Psychology, Social Work or health related field or equivalent experience.
  • Knowledge on different insurance company plans and systems regarding targeted case management preferred
  • Knowledge of Mental Health Disorders
  • Knowledge of Medicaid HMO’s
  • Excellent customer service, interpersonal, and communication skills
  • Able to follow directions quickly and efficiently with varying workloads and interruptions. Must be able to work well under pressure and deal with co-workers in a positive manner
  • The ability to solve problems, resolve errors, function effectively in stressful situations, make corrections and improvements and make decisions in a logical, reasonable manner
  • The ability to accept instruction and constructive criticism and to apply such to follow through to affect changes
  • The ability to organize and prioritize assignments, duties, and responsibilities

CORE COMPETENCIES:

  • Maturity and sensitivity to the special needs of PPBH clients while possessing the knowledge of behavioral health and medical conditions.
  • Ability to utilize and navigate an electronic health record, Microsoft office software, and insurance verification websites.
  • Possess the ability to document the services provided to customers and maintain medical records in accordance with established governing standards in a timely, legible, accurate and complete manner.
  • Ability to recognizes, evaluates, gather collateral information and develop interventions to address risk factors related to potential for violence and dangerousness to self or others.
  • Ability to communicate client needs and information to behavioral healthcare staff.
  • Must be service oriented with good customer service skills.
  • Must possess the ability to maintain client confidentiality.

REQUIREMENTS:

  • A valid Class E Drivers’ License for positions that require driving personal or Agency vehicle on Agency business.
  • Must maintain a minimum Bodily Injury & Property Liability insurance limit of at least $50,000 for positions that require driving personal own vehicle (POV) on Agency business.
  • PPBH is a 24/7 Agency. All employees must be available as needed when required.

 

ESSENTIAL DUTIES AND RESPONSIBILITIES:

  1. Complete outpatient request forms which include diagnosis, medications, symptoms and behavior, risk factors, goals, objectives and treatment for initial and reoccurring clients. Forms must be signed and faxed over to proper insurance company
  2. Read client Psychiatric Evaluations, Co-occurring Assessments, Needs Assessment, Service Plans, goals, objective and treatment to complete request forms effectively
  3. Communicate with insurance company for status or issues on requests submitted
  4. Retrieve prior authorization/reference numbers and input it in data base
  5. Provide manager, Target Case Manager/PSR Director, and TCM’s with approved or denied requests, authorization/reference numbers, dates, and any information needed
  6. Submit appeals for denials in a timely manner
  7. Verify Medicaid eligibility for all PSR and CM clients on the first business day of each month so as to ensure that the correct payor is in CCP and authorizations, if necessary, are requested in a timely manner
  8. Thoroughly look through weekly reports for expiration dates, and remaining units
  9. Requests prior authorizations for clients who have changed insurances
  10. Communicate with Billing department and TCM’s if insurance has been terminated and services should no longer be provided
  11. Performs other related duties as assigned by manager.

COMPUTER SKILLS:

Must have Intermediate to advanced experience in MS Office Suite (Outlook, Word, Excel, PowerPoint), the use of personal computers, and standard office productivity software.

LANGUAGE SKILLS:

Ability to read and interpret documents such as safety rules, operation and maintenance instructions, and procedure manuals.

PHYSICAL DEMANDS:

The physical demands here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to use hands to finger, handle, or feel objects, tools, or controls and reach with hands and arms.  The employee is occasionally required to stand; walk; sit; climb or balance; stoop; kneel; crouch; or crawl; and talk or hear.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

DEPARTMENT: Utilization Review

EMPLOYMENT TYPE: NON-EXEMPT/FULL TIME

To apply for this job email your details to KirstenF@ppbh.org


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