Medical Authorization Assistant (Concurrent Review)

CalOptima - Orange, CA3.6

The Medical Authorization Assistant (MA) provides office and referral management support services and assists the inpatient Case Managers in obtaining medical records, documenting all case information in the system, performing data entry into appropriate databases for monitoring and tracking, and following up on phone calls as directed by the Case Managers. The MA serves as a contact between members, physicians, facilities, providers and CalOptima staff, processing the intake of information, assisting with authorization functions and gathering information. This position is responsible for providing effective, efficient and courteous interaction with facilities, providers, members and their family, and other CalOptima staff, under the direction of the Registered Nurse. The MA may also perform office support functions as required.

Position Responsibilities:
Receive inpatient requests via fax, phone, or electronically and enters data of the new case information into the medical management system.
Create inpatient events based on facility face sheets and/or clinical received.
Verification of member eligibility.
Collect additional information from CalOptima members and/or providers/facilities to complete prospective, concurrent or retrospective inpatient service reviews.
Authorize requested services according to CalOptima’s Concurrent Review Team guidelines, performing data entry into the authorization system, and verifying eligibility. Contact the health networks and/or CalOptima Customer Service regarding health network enrollments.
Assist the inpatient Case Manager in gathering medical records, obtaining appropriate coding for diagnosis and procedures, discharge dates, dispositions, and conducts follow up phone calls per concurrent review team standards.
Perform discharge follow up duties as assigned.
Document all contacts and case information in the system using the standard charting format.
Perform data entry into the appropriate databases for monitoring and tracking, trending of inpatient events and other relevant databases as needed.
Provide customer service to providers and members.
Other projects and duties as assigned.

Required Skills

Effectively communicate both verbally and in writing to obtain relevant data from members, providers, etc., and record and summarize findings.
Communicate with individuals from varying cultural and ethnic backgrounds.
Utilize Concurrent Review protocols to determine when to refer matters to licensed staff.
Develop and maintain effective working relationships with all levels of staff, other programs, community agencies, providers and members.
Effectively utilize computer and appropriate software and interact as needed with CalOptima Information Systems.

Required Experience

Experience & Education:
High school diploma or equivalent required.
2 years of related experience that would provide the knowledge and abilities listed.
Bilingual in English and one of CalOptima’s defined threshold languages is preferred.

Knowledge of:
Computers, keyboarding, appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Medical terminology.
ICD-10 and CPT coding.
Medi-Cal and Medicare benefits and regulations.

Grade: H