Job Summary:
Reports directly to the Lead Authorization Coordinator and responsible for collecting, processing and monitoring routine to moderate complex referrals and health care services data. Also responsible for verifying benefits to customers in an effort to improve these services using established policies, procedures and guidelines.

Essential Duties and Responsibilities:
• Inputs and processes authorization requests and auto-authorizations per guidelines and according to defined time and accuracy standards.
• Ensures correct and consistent application of decision support system i.e., Medical management Guidelines, Milliman Care Guidelines.
• Provides customers with verification of eligibility, interpretation of benefits, and appropriate contracted provider/facility.
• Maintains effective communication with inpatient facilities, providers, and other UM/CM staff.
• Screens and troubleshoots calls regarding member care within scope of a non-clinical position. Routes members and provider calls outside that scope to appropriate department.
• Administers reports and maintains files of correspondence, denial and appeal logs, documentation of materials to support report status and clinical workflow.
• Applies appropriate contracted, negotiated, or DRG rates using established criteria.
• Performs other duties that may be assigned from time to time.

Education and Experience:
1. High School diploma or equivalent.
2.  Minimum of 2 years experience with impressive track record in collecting, processing and monitoring routine to moderate complex referrals and health care services data.
3. Effective team player with very good interpersonal relationship skills and can work and relate well with co-employees, patients and customers.
4. Must have the behavioral sensitivity, maturity, diplomacy and tact in addressing complex situations and handling irate customers.
5. Outstanding oral and written communication skills.
6. Strong ethics and a high level of personal and professional integrity.
7.  Must have basic familiarity on federal and state laws and requirements relating to healthcare management.
8. Computer literate and very highly proficient in using MS office programs.