Prior Authorization Coordinator (DME)
Lakeside Medical
 Orange, CA

As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

The role of the Prior Auth/DME Coordinator is to promptly, efficiently and accurately execute all aspects of the referral process. Facilitating the right care at the right time in the right setting. Process requests from Access Express that are pended or reprocess approved or denied auths and package properly for review and resolution. Check eligibility and benefits on all DME and home health authorizations prior to forwarding on request to prior authorization nurse or medical director for approval. Capture any leakage and provide feedback to the leadership team for additional training. Maintain turnaround time compliance in all aspects of the Prior Authorization process. Promote the quality and cost effectiveness of medical care through strict adherence to all UM Policy and procedure.

Essential Duties and Responsibilities include the following:

  • Understand and execute the principles of Prior Authorization to facilitate the right care at the right time in the right setting and understand and comply with DME requirements
  • Perform all assistant and coordinator job functions.
  • Able to solve complex prior authorization and DME questions and issues.
  • Effectively handle all incoming provider calls including the most challenging provider offices.
  • Identified trends with provider offices and interfaces with those provider offices.
  • Request Network Management training or on site visit to provider offices needing reinforcement.
  • Identify issues that need to be escalated to a lead or supervisor.
  • Identify opportunities for improvement and make recommendations for change.
  • Process requests from Access Express that are pended or reprocess approved or denied auths and package properly for review and resolution.
  • Check eligibility and benefits on all items requiring a benefit check such as DME and home health authorizations prior to forwarding on request to prior authorization nurse or medical director for approval.
  • Capture any DME leakage and provide feedback to the leadership team for additional training.
  • Maintain turnaround time compliance in all aspects of the Prior Authorization process.
  • Work in collaboration with the department Prior Auth Assistants, Specialists, Team Leads, Supervisor, Managers and Regional Medical Directors and Network Managers to ensure a level of referral processing that meets or exceeds the organization's expectation.
  • Recognize when an error has been made and immediately report it to the appropriate supervisor or manager.
  • Maintain quality monitors as assigned by Supervisor.
  • Complete assigned tasks accurately and within specified time limits.
  • Treat co-workers and customers with patience and respect.
  • Assist other staff and support the team approach.
  • Participate in the efficient, effective, and responsible use of resources such as supplies and equipment.
  • Communicate appropriately and clearly to management, co-workers, and physicians.
  • Maintain all reference material that is provided by the supervisor, manager or director.
  • Know and follow the Employee Handbook policies and procedures.
  • Maintain patient confidentiality so that HIPAA compliance is observed at all times.
  • Demonstrate honesty and integrity in everyday activities.
  • Arrive to work on time. Consistently be at work. Display flexibility regarding lunches, breaks and work hours.
  • Willingness to work overtime when requested.
  • Other Duties as assigned.

Policies:

  • Communicate verbally and in writing through appropriate channels.
  • Maintain confidentiality and follow HIPAA policies.
  • Follow dress code.
  • Use time clock appropriately.
  • Participate in staff meetings.
  • Notify supervisor in writing of time off requests.
  • Be courteous and promote professionalism.
  • Be flexible and adaptable.
  • Promote organizational goals.
  • Know and follow safety standards.