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Prior Authorization Coordinator, South San Francisco, CA

Health Plan of San Mateo


South San Francisco, CA

February 27, 2019


The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Prior Authorization Coordinator whom will have Multi-functional responsibilities within the Prior Authorization team in the Utilization Management (UM) department. The PA Coordinator is responsible for participating in the facilitation of the regulatory compliance and audit processes. Specifically this includes audit duties in support of response to external audit requests, internal UM case file reviews and daily operational monitoring. With guidance from Manager or Supervisor, this role will conduct some analysis, review work, and provide explanation and interpretations within their area of expertise.

The essential duties and responsibilities will include the following:

  • Assists in the preparation of reports that analyze and track quality of service and utilization statistics; develop and implement quality monitoring and reporting for the Prior Authorization unit
  • Coordinates and assists in audit preparing including file preparations, quality assurance, managing UM reports, and etc.
  • Ensure all required documentation (e.g. manuals, policies, requested files, etc.) requested by auditing bodies are available for review for on-site, remote, and webinar audits.
  • Pre-review files and materials requested for audits, provide summary of findings so that issues can be shared with the Operational Areas prior to submission
  • Under the direction of Manager or Supervisor, will participate in focused audits to identify operational compliance with processes
  • In preparation for an audit, will run reports out of audit systems which summarize monitoring activities, to identify operational compliance with processes
  • Participate in on-site/webinar audits, as needed
  • Maintain understanding of business rules and regulatory requirements pertaining to UM processes
  • Provide administrative and clerical support for utilization management activities through data entry, member tracking, analytical work, and non-clinical research
  • Create, maintain, and monitor daily and weekly reports to ensure compliance with regulatory standards
  • Assist in performing root cause analysis (RCA) for identified concerns pertaining to timeliness standards, customer service, provider call volume, audit findings, and etc.
  • Assist in completing work within queues that are used to manage authorization requests
  • Serve as back up to Authorization Specialist duties such as manual data entry, and provider calls/outreaches
  • Maintain Desk Procedures
  • Perform other duties as assigned


Education and Experience: Associate of Arts Degree required. Equivalent work experience may be substituted for educational requirement on a year for year basis. Two (2) years of Utilization Management experience required. Minimum of three (3) years relevant experience such as working in a medical office/practice, acute care hospital, managed care health plan, etc. Knowledge of UM systems ( preferred)

Knowledge of: Managed Care Processes including use of Milliman Care Guidelines, Medi-Cal (Title 22), and Medicare. Working knowledge if all relevant federal, state, and regulatory requirements. Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access, and PowerPoint

Ability to: Work cooperatively with others. Work as part of a team and support team decisions. Multi-task with demanding timeframes. Communicate effectively, both verbally and in writing. Adapt to changes in requirements/priorities for daily and specialized tasks.

Compensation and Benefits

Starting Compensation Range: - Depending on Experience

Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s Medical, Dental and Vision coverage. Employee pays a small portion of the dependent premiums (5%) for medical and dental benefits. Additional HPSM benefits include fully paid life, AD&D, and LTD insurance; retirement plan (HPSM contributes equivalent of 10% of annual compensation); holiday and vacation pay; tuition reimbursement plan; onsite fitness center and more.

How to Apply

Application Process: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 801 Gateway Blvd., Suite 100, South San Francisco, CA 94080 or via email: or via fax: (650) 616-8039. File by: Continuous until filled. The Health Plan of San Mateo is proud to be an Equal Opportunity Employer and encourages minority candidates of all backgrounds to apply.

Submissions without a Cover Letter and Salary Expectations may not be considered.

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