• Prioritize incoming authorization and referral requests according to queue urgency
• Review patient’s clinical and chart documentation related to the service submitted by the provider’s office
• Obtain and/or follow up on authorization and referral requests from the patient’s payer/s through any of the following methods—depending on the payer’s policy:
• Perform outbound calls to payer’s authorization department
• Access payer’s authorization online portal
• Submit faxes to payer’s authorization department
• Respond to payer’s clinical questions to be able to proceed with the authorization and referral requests
• Obtain and/or follow up payer’s peer-to-peer review requirements and send them back to provider’s office for the actual initiation
• Cater inbound calls from payers and perform necessary actions required for the task
• Listen and review voicemail messages from payers then perform necessary actions required for the task
• Monitor activities of Nurses to assess schedule adherence, accuracy, quality, productivity, timeliness and compliance with job requirements, policies and procedures. Report updates to management.
• Provide basic on-the-job training for direct reports and serve as a resource to address questions related to the policies, processes and procedures.
• Monitor, identify and resolve performance/behavior/attendance issues using prescribed performance management techniques.
• Adhere to all company policies and procedures.
• Adjust to the needs of meeting service level agreements under supervision of Manager.
• Ensure training needs of team members are met.
• Successfully complete all client related training and keep record of the same.
• Hold team briefings on a daily basis with the team.
• Communicate all process and client changes to direct reports within specific timelines and keep record of such updates.
• Act as a single point of contact for the assigned team members for all their job related needs and create a harmonious work environment.
• Escalate performance related issues with respect to assigned team members to Managers on a timely manner (PIP).
• Responsible for day-to-day functional supervision of work group, including work assignment and attendance monitoring; providing input into selecting, training, developing, and completing performance appraisal of work group(s) in accordance with the organization’s policies and applicable compliance requirements.
• Employee separations to be handled in-line with company policies and HR

Required Skills

• Solid understanding of anatomy & physiology, including how body systems function and an understanding of disease processes
• Comprehensive understanding of Medical Terminology
• Prior experience in processing multispecialty authorizations including contact with payers
• Experience in prior authorization process
• Experience with general computer software (Internet, Word, Outlook, PDF required)
• Proficiency to learn new software programs quickly
• Excellent customer service skills: communicates clearly and effectively
• Excellent verbal and written communication skills
• Professional and effective interaction skills with co-workers, clients, providers, and vendors
• Proven ability to work well individually and as a team member
• Strong attention to detail
• Ability to follow company and account-specific standard operating procedures and policies
• Ability to adapt to constantly changing environment
• Ability to prioritize and organize multiple tasks by remaining focused and quality-driven at all tasks at hand
• Ability to remain organized with multiple interruptions
• Ability to make decisions independently without bypassing any company and account-specific standard operating procedures and policies
• Ability to comfortably receive constructive feedback

Required Experience

• Graduate of Bachelor of Science in Nursing with active PH registered nurse license
• Bachelor's Degree in Nursing with active PH Registered Nurse license
• Minimum 2 years of Team Lead experience in a US Healthcare account (Prior Authorization or Claims/Denial/Appeal)
• Excellent Leadership & Interpersonal relationship
• Strong Process Management & planning skills
• Embrace change and think operationally to achieve business goals
• Proven process improvement experience