General CSA Duties and Responsibilities:

• Timely answering of inbound calls in the Health Services’ phone queues
• Make outbound calls to providers, members, and CenCal Health staff regarding operational processes
• Timely communication of conflicts or difficulties with members or providers to the immediate supervisor
• Maintain confidentiality and privacy of member information in adherence to HIPAA and Confidentiality laws and regulations
• Adhere to CenCal Health’s mission, protocols, policies and procedures and meet required performance standards
• Timely attendance of Company-wide and department meetings and trainings and, as appropriate, actively participate
• Respond to emails, telephone calls, and other modes of communication promptly, professionally and courteously
• Interact with CenCal Health employees, members, and providers professionally

The CSA will be assigned to a core unit (UM, CM, CC, DM, BH or Pediatric).

• Answer inbound calls from unit phone queue and make outbound calls to providers and members regarding authorization request status
• Accurately enter authorization requests and submitted documents into the authorization system
• Obtain all necessary documentation required to process referrals and requests for covered services
• Respond to inquiries regarding the authorization processes and request statuses from providers, members and staff from other departments
• Act as a liaison between clinical reviewers and providers/members
• Accurately enter billing and diagnosis codes, category and type of service, amount, frequency, and/or volume of requested or approved services and procedures
• Process authorization requests within established timeliness standards
• Track and monitor timeliness of service authorization and referral requests
• Accurately prepare, edit and finalize written determination notices to providers and members
• Prepare timely and accurately formatted notices and retain/store documents related to authorization request and determination notices
• Verify eligibility and/or other payor source
• Collaborate and communicate with other Health Plan departments such as, but not limited to, Member Services, Providers Services and Claims
• Inform members and providers of the authorization and appeal processes
• Adhere to authorization timelines of Federal and State agencies that govern health plan operations
• As directed, process long term care recertification
• As directed, process inpatient authorization request
• Process limited authorization request according to written guidelines
• Work closely with the clinical team, which includes physicians, nurses, and social workers
• As assigned, telephonically screen the member’s well-being and/or make contact to their family or authorized representative
• As assigned by the clinician, perform tasks identified in a member-centered care plan to meet or progress toward established goals or outcomes
• As assigned, follow members who are in the lowest level of case management or care coordination services
• Promptly communicate any changes in a member status to the assigned clinician
• Organize, schedule, track and monitor member contacts
• Submit accurate reports and complete documentation in a timely manner
• Perform timely outreach calls to members
• Assist members with completing health surveys
• Generate and mail post-program satisfaction survey; and as necessary, perform outreach calls
• Adhere to department protocols and procedures for electronic data entry and form completion
• As requested, participate in the case conference and care plan development
• Provide members with community and referral resources that may benefit their ability to self-manage their condition and/or maintain their independence
• Work collaboratively with the clinical team to monitor the member’s adherence to their established care plan
• Act as an advocate for the member, recognizing the member’s individual values