Personal Care Management Prior Authorization Processing Specialist

Summary/Objective: The position of Prior Authorization Specialist is a role that requires in depth knowledge of the PCA program rules and regulations, and Standard Operating Procedures of the Optum/MassHealth Prior Authorization Unit (PAU). This position requires daily management of submission of MassHealth Evals for the PCA program in a timely manner, with proper prioritization to prevent a PA Extension. Thie role will provide consistent follow-up with the PA dept staff, Quality Assurance/Document Imagine, PCM Skills Trainer leadership to obtain completed documents, and PCM Eval department documents. Must be effective in delivering consistent results, maintain a high level of knowledge of all tasks within the department, and able to work effectively with accuracy in data input.

Essential Functions

• Follow PCA Program requirements, MassHealth rules, contracts, and PAU standards.
• Track PAs that will expire within 31 days and take appropriate action.

• Manage PA requests, including new requests, extensions, deferrals, adjustments, and resubmissions.
• Review PAs to make sure all information and required documents are complete and accurate.
• Identify missing or incorrect information and follow up to get the needed documents.
• Identify PAs that need clinical review or adjustments.
• Work with nursing/clinical staff to obtain required documentation and physician signatures.
• Submit and track PA adjustments until they are resolved.
• Follow up on deferrals and resubmit requested information within the required timeframe.
• Process PA extensions according to MassHealth and PCM requirements.

• Process deferrals through resolution, including obtaining requested information, resubmitting documentation within required timeframes, and monitoring outcomes.
• Process extensions in accordance with MassHealth requirements and PCM procedures, including identifying the reason for the extension and ensuring appropriate documentation is submitted.
• Review and appropriately escalate extensions exceeding 90 days to PCM leadership, including providing rationale and supporting information.
• Monitor PA status and proactively address pending, expiring, denied, deferred, or otherwise unresolved authorizations to prevent service interruptions.
• Process Transition of Care Prior Authorizations for consumers transitioning from Integrated Care to Fee-for-Service, ensuring all required information is obtained and processed timely.
• Communicate directly with MassHealth PAU and PCM leadership to clarify complex, unusual, or uncertain processes and resolve authorization-related issues.
• Work effectively in a hybrid work environment, maintaining productivity, communication, availability, and service standards while working remotely and onsite as required by departmental and business needs.
• Perform other duties and responsibilities as assigned.
• All other duties assigned by the PCM Administrative Supervisor.

Competency

• Demonstrates strong knowledge of the PCA program Fee -for- Service Prior Authorization requirements, MassHealth requirements, and applicable Optum Prior Authorization processes.
• Independently reviews processes, and monitors Pas for completeness, accuracy appropriate dates, units’ documentation and required clinical/ consumer.
• Understands and applies PCM contractual requirements, MassHealth regulations and established Prior Authorization policies and procedures.
• Identifies and appropriately resolves complex in complex, or escalated PA cases, including missing documentation discrepancies denials, extensions, and corrections
• Analyzes issues, determines appropriate next steps, evaluations available information, and reasonable recommendations.
• Maintains a high level of accuracy when reviewing consumer information clinical documentation, PA requests and support records
• Effectively organizes and prioritizes a high-volume workload while meeting established productivity, quality, and turnaround expectations

• Clearly communicates with internal teams, providers, consumers, and external partners regarding PA requirements, outstanding information, status, and resolution of issues.
• Maintains accurate and timely documentation of PA activity, follow-up efforts, decisions, and outstanding requirements.
• Identifies workflow issues and opportunities to improve PA processing, accuracy, efficiency, and service delivery.

• Perform all other duties as may be required.

Education

High School Diploma

Work Environment

This job operates in a professional office environment. This role routinely involves standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

While performing the duties of this job, the employee is regularly required to talk and/or hear. The employee is frequently required to sit; use hands to finger, handle or feel; and reach with hands and arms.

Travel

No travel is required for this position.

Other Duties

Note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.