Job Description
Responsibilities: - Review approximately 20 prior authorization (auth) requests daily , Monday-Friday.
- Complete all reviews and submit them to the UM Coordinator before 3:00 PM PST .
- Evaluate each auth by reviewing:
- Member's medical records
- Auth request details
- Relevant clinical criteria (CMS, Health Plan, InterQual, MCG)
- For denied or partially approved requests , provide:
- A clear, detailed rationale
- Cited criteria including name, title, and number
- Monitor your assigned auth queue in the UM system.
- Ensure that all auths are reviewed and returned within the assigned turnaround times (TAT), color-coded as:
- Red: Past due
- Yellow: Nearing deadline
- Green: Over 24 hours remaining
- Notify the team in advance for scheduled time off ; unreviewed auths must be carried over and completed the following day.
- Provide 24-hour notice for unscheduled time off , when possible.
- Collaborate with the UM team and follow protocols for criteria application and review submission.
Training Provided: - Training on our Prior Authorization system and workflow
- Instruction on how to cite criteria appropriately
- Criteria documents will be attached to each auth for your review
Additional Notes: - This is a remote, part-time contract role
- Reviewers are expected to consistently meet the 20-auths-per-day quota
- Queue monitoring and daily communication with the UM team are essential for success.The pay range for this position at commencement of contract is expected to be between $6,000.00 - $6,000.00 per month.
- Active, unrestricted California medical license (MD or DO)
- Strong clinical decision-making and documentation skills
- Familiarity with CMS guidelines, InterQual, MCG, and major health plan criteria
- Ability to work independently and meet strict daily deadlines
- Comfortable working with digital systems and remote teams
Job Tags
Contract work, Part time, Monday to Friday,