Medical Authorization Assistant (Utilization Management)

Department(s):  Utilization Management
Reports to:  Supervisor, Concurrent Review
FLSA status:  Non-Exempt
Salary Grade:  C - $43,281 - $61,798

Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on Monday, December 4, 2023 at 11:59 PM.  Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. 

About CalOptima Health

Are you looking for a career that changes lives? As the single largest health plan in Orange County, CalOptima Health serves one in three residents with health insurance programs for low-income children, adults, seniors and people with disabilities. Our 1,500 employees are valued for their individual perspectives and contributions and benefit from flexible work schedules, recognition and opportunities to grow. If you're looking for a rewarding career supporting a meaningful mission, along with generous benefits and recognition, consider joining us at CalOptima Health!

About the Position

The Medical Authorization Assistant will provide office and referral management support services. The incumbent will assist the Utilization Management (UM) 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 incumbent will serve as the contact between members, physicians, facilities, providers and CalOptima Health's staff. The incumbent will be responsible for processing the intake information and assisting with authorization functions.

Duties & Responsibilities:

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Receives both inpatient and outpatient referral requests via fax, phone or electronically, enters data of new case information into the medical management system.
• Creates events-based on facility face sheets, authorization referral forms and/or clinical received.
• Verifies member eligibility.
• Collects additional information from CalOptima Health's members and/or providers/facilities to complete prospective, concurrent or retrospective service reviews.
• Authorizes requested services according to CalOptima Health's UM department guidelines.
• Contacts the health networks and/or CalOptima Health's Customer Service department regarding health network enrollments.
• Assists the UM Case Managers in gathering medical records, obtaining appropriate coding for diagnosis and procedures, discharge dates, dispositions and conducts follow up phone calls per UM team standards.
• Documents all contacts and case information in the system using the standard charting format.
• Enters data into the appropriate databases for monitoring and tracking, trending of inpatient events and other relevant databases.
• Completes discharge follow up duties as assigned.
• Performs office support functions, as needed.
• Completes other projects and duties as assigned.

Experience & Education:

• High School diploma or equivalent required.
• 2 years of experience in a health care or managed care setting required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

Preferred Qualifications:

• Previous medical billing and coding experience.
• Certified Medical Assistant (CMA) certification.
• Concurrent Review and UM experience.
• Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).

About our Benefits & Wellness options:

At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.

CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.

CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.