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/Mass Health Prior Authorization Unit (PAU). This position requires daily management of submission of Mass Health 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.

• Follow PCA Program requirements, Mass Health 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 Mass Health and PCM requirements. Process deferrals through resolution, including obtaining requested information, resubmitting documentation within required time frames, and monitoring outcomes.
• Process extensions in accordance with Mass Health requirements and PCM procedures, including identifying the reason for the extension and ensuring appropriate documentation is submitted.
• Review and appropriately escalated 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 Mass Health 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.

• All other duties assigned by the PCM Administrative Supervisor.
• Competency Demonstrates strong knowledge of the PCA program Fee
  -for
  - Service Prior Authorization requirements, Mass Health 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, Mass Health 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…