• Processing all incoming prior authorization and referral requests involving several state Medicaid members • Managing the intake process, referrals, eligibility verification, member demographic review and other related functions to the prior authorization or referral requests • Ensures correct prior authorization/referral form is completed for patient’s plan • Reviews medical necessity documents for accurate information to include patient provider identification information, clinic or procedure requested, and appropriate CPT/Diagnosis codes to verify the accuracy and completeness of information submitted by healthcare providers • Ensures diagnoses, procedures, and services are correctly documented, in accordance with industry standards and regulatory requirements • Validates the appropriateness of prior authorization requests and referrals based on established policies, contracts, and medical guidelines • Identifies discrepancies or inconsistencies and appropriately communicate them for further investigation • Monitors prior authorization requests and referrals processing activities to ensure adherence to legal and regulatory requirements, such as HIPAA, CMS guidelines, and contractual obligations • Updates systems with patient information and actions to ensure timely claims payment • Achieves daily, monthly, and quarterly quality and productivity KPIs • Secures patient demographics and medical information, ensuring HIPPA compliance