Aetna VA MCD Prior Auth Rep in Richmond, Virginia

Req ID: 55571BR

Position Summary

The Prior Authorization Representative supports comprehensive coordination of medical services including intake, screening and referrals to Aetna Medical Services Programs. Promotes/supports quality effectiveness of Healthcare Services.

Job Responsibilities:

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 services (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.

Background/Experience desired:

Minimum of 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. Prior MCO and behavioral health experience is a plus.


The highest level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.

Functional Experiences

Functional - Customer Service/Customer service - transaction based environment/1-3 Years

Functional - Customer Service/Customer service - production environment/1-3 Years

Functional - Administration / Operations/Data Entry/1-3 Years

Functional - Administration / Operations/File Maintenance/1-3 Years

Functional - Communications/Provider communications/1-3 Years

Technology Experiences

Technical - Desktop Tools/Microsoft Word/1-3 Years/End User

Technical - Desktop Tools/TE Microsoft Excel/1-3 Years/End User

Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User

Technical - Desktop Tools/Microsoft SharePoint/1-3 Years/End User

Required Skills

Benefits Management/Interacting with Medical Professionals/ADVANCED

Service/Demonstrating Service Discipline/FOUNDATION

Technology/Leveraging Technology/FOUNDATION

Desired Skills

General Business/Communicating for Impact/ADVANCED

Service/Providing Solutions to Constituent Needs/FOUNDATION

Service/Working Across Boundaries/FOUNDATION

Additional Job Information

Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of Virginia is looking for people like you who value excellence, integrity, caring and innovation. As an employee, youll join a team dedicated to improving the lives of Virginia Medicaid members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of Virginia, and we will support you all the way.

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.

Aetna takes our candidates's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Job Function: Health Care

Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.