Aetna OH/TX DSNP Prior Auth Rep in New Albany, Ohio
Req ID: 52214BR
Provides comprehensive healthcare management to facilitate delivery of appropriate quality healthcare, promote cost effective outcomes and improve program/operational efficiency involving clinical issues. Supports comprehensive coordination of medical services including intake, screening and referrals to Aetna Medical Services Programs. Promotes/supports quality effectiveness of Healthcare Services.
Performs intake of calls from members or providers regarding services via telephone, fax, EDI. Utilizes Aetna systems to build, research and enter member information. Screens requests for appropriate referral to medical services staff. Approve services that do not require a medical review in accordance with the benefit plan. Performs non-medical research including eligibility verification, COB, and benefits verification. Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements. Promotes communication, both internally and externally to enhance effectiveness of medical management service (e.g., claim administrators, Plan Sponsors, and third party payers as well as member, family, and health care team members respectively) Protects the confidentiality of member information and adheres to company policies regarding confidentiality Communicate with Aetna Case Managers, when processing transactions for members active in this Program Supports the administration of the precertification process in compliance with various laws and regulations, URAQ and/or NCQA standards, where applicable, while adhering to company policy and procedures. Places outbound calls to providers under the direction of Medical Management Nurses to obtain clinical information for approval of medical authorizations. Uses Aetna Systems such as QNXT, ProFAX, ProPAT, and Milliman Criteria. Communicates with Aetna Nurses and Medical Directors, when processing transactions for members active in this Program. Sedentary work involving significant periods of sitting, talking, hearing and keying. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor. Working environment includes typical office conditions.
2-4 years experience as a medical assistant, office assistant or other clinical experience. Previous experience working with providers and provider networks preferred. Call center experience, strongly preferred. Knowledge/Experience with Medicaid highly desired.
The highest level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.
Benefits Management/Interacting with Medical Professionals/ADVANCED
General Business/Maximizing Work Practices/ADVANCED
ADDITIONAL JOB INFORMATION
Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members. Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word. Ability to effectively participate in a multi-disciplinary team including internal and external participants. Familiarity with basic medical terminology and concepts used in care management. Effective communication, telephonic and organization skills. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone, and typing on the computer. Typical office working environment with productivity and quality expectations
Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.
We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.
Together we will empower people to live healthier lives.
Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.
We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
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Job Function: Health Care