<ul> <li> <p>Analyzes, researches, and interprets medical and claims data while processing authorization requests. This includes:</p> </li><li> <p>Authorizes requests that clearly meet specified criteria according to department guidelines.</p> </li><li> <p>Refers requests to Medical Directors for determination when appropriate following department and regulatory guidelines.</p> </li><li> <p>Ensures necessary medical record information, previous review determinations and other member-specific data are sufficient to make determinations.</p> </li><li> <p>Requests any missing information according to medical policy and benefit guidelines following department standards and regulatory statutes.Ensures requests are processed within regulatory timeliness guidelines.</p> </li><li> <p>Maintain productivity rate and meet requirements for accuracy and timeliness for Private Business.</p> </li><li> <p>Communicates final case determinations in writing and by telephone providing complete and accurate information using appropriate templates per department and regulatory guidelines. Documents accurately and completely in a timely manner.</p> </li><li> <p>Resolves incoming routine inquiries from members and providers received by telephone, correspondence or email.</p> </li><li> <p>Ensures quality outcomes by tracking, researching and documenting updated benefit/medical policy information, unit workflows and inquiry resolution as well as participating in quality improvement activities such as inter-rater reliability reviews.</p> </li><li> <p>Performs all other miscellaneous responsibilities and duties as assigned or directed.</p> </li></ul> <p>#LI-Hybrid</p> <ul> <li>Associates degree and one year of related work experience or an equivalent combination of education and/or experience. </li><li>Effective written and verbal communication skills. </li><li>Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook. </li></ul>