L441
Located in Grants Pass, OR
Pay: $21-$23
Job Full Description
The Physical Health Analyst II is responsible for processing and conducting initial reviews of referrals and prior authorizations in compliance with applicable government and health plan policies. This role ensures timely and accurate service determinations while maintaining effective communication with members, providers, and internal teams.
Essential Duties:
- Process service determination requests for assigned service types.
- Conduct outreach for supporting documentation from members and providers.
- Provide timely oral and written notifications to members regarding service determinations.
- Monitor compliance and adherence to service determination timelines and standards.
Key Responsibilities:
- Verify member eligibility and benefit coverage across all insurance products.
- Make initial determinations on requests per organizational policies and procedures.
- Prepare detailed service determinations for clinical review, including comprehensive member history.
- Request and collect supporting medical records as necessary for service determination reviews.
- Ensure service determinations are processed within mandated government timeframes.
- Research and apply relevant federal, state, and health plan policies for service determinations.
- Assist provider offices with training on the Provider portal and authorization request submissions.
- Communicate service determinations orally and inform members of their grievance and appeal rights.
- Accept grievances or appeals from members or providers and process accordingly.
- Draft written notifications for service determinations (favorable, adverse, or extensions).
- Build and maintain professional relationships with providers, ensuring courteous and effective communication.
- Serve as a product specialist for benefit and authorization inquiries.
- Identify workflow inefficiencies and propose solutions for process improvements.
- Recognize members who may benefit from Care Coordination and initiate internal referrals.
- Participate in on-call responsibilities, including scheduled check-ins as required by the department.
Qualifications:
- Bachelor’s degree in a related field or equivalent experience preferred.
- Previous experience in healthcare, specifically in referral and prior authorization processes, is highly desirable.
- Strong understanding of insurance products and relevant government regulations.
- Excellent written and verbal communication skills.
- Ability to work independently and collaboratively within a team environment.
- Strong organizational skills and ability to manage multiple tasks efficiently.
- Proficient in Microsoft Office Suite and familiarity with healthcare management software.
On-Call Responsibilities:
This position requires participation in a rotational on-call schedule during weekends, as determined by departmental needs. The Specialist will be expected to be available during assigned on-call hours to respond to urgent requests and ensure compliance with service standards.
Work Environment:
- Ability to maintain composure in high-pressure situations.
- Regular attendance and punctuality are essential.
- Must adhere to all required training, including those listed in the Relias Learning Module System (LMS).
- Other duties may be assigned as needed.
Medford, OR
1951
3523 Arrowhead Drive
Suite 100
Medford, OR 97504
Apply Now Email Us