Prior Authorization and Referral Specialist

Role:

The Prior Authorization Specialist is responsible for obtaining prior authorization and/or predeterminations, from payers for inpatient and outpatient services provided by Hutchinson Clinic providers. The Prior Authorization Specialist collects demographic, insurance, and clinical information from patients to ensure that all reimbursement requirements are met.

Essential Functions and Responsibilities:

• Researches all information needed to complete the referral/precertification process.
• Understands insurance requirements for prior authorizations. Serves as a primary resource to all clinic staff regarding prior authorization requirements for all services provided.
• Collects and reviews clinical data, medical terms, diagnosis, medical history, and procedure codes (without the need for interpretation) and follows established procedures for authorizing requests
• Contact payer to obtain prior authorization. Gather additional clinical and/or coding information, as necessary, in order to obtain prior authorization. Enter prior authorization information into Allscripts Practice Management to ensure accurate and timely claims filing.
• Verify that all insurance requirements for outpatient and/or inpatient procedures have been met.
• Advise providers and their clinical staff when issues arise relating to obtaining prior authorization. If necessary, notify Patient Financial Services of uninsured situations.
• Regularly attends and participates in assigned meetings. Stay informed and research information regarding new procedures and insurance coverage positions
• Educate providers and their clinical staff regarding the prior authorization process.
• Knows and consistently implements the organizations mission and all approved policies, protocols, and procedures.
• Regularly supports compliance and accreditation efforts as assigned (e.g. OSHA, HIPAA)
• Consistently demonstrates good use of time and resources.
• Communicates effectively and professional with patients, staff, and providers
• Performs other duties that may be assigned from time to time.

Performance Measurements:

• Performs all Essential Job functions and responsibilities.
• Maintains a professional and positive attitude, appearance and relationship with patients and staff.
• Observes all clinic guidelines and polices.

Knowledge and Skills:

• Experience: Up to 6 months in a similar or related healthcare position.
• Education: High School Diploma or GED equivalent. Knowledge in medical service coding is preferred. Familiarity with medical terminology or willingness to learn.
• Interpersonal Skills: Ability to deal with customers, courteously, politely, and effectively. Knowledge of EMR system. Must demonstrate consistent professional conduct. Must possess excellent verbal and written communication as well as excellent interpersonal skills with patients, staff, and other health care professionals.

Physical Requirements:

• Ability to use a computer keyboard and mouse 6-8 hours per day
• Ability to dial, answer, and talk on the telephone for 6-8 hours per day
• Vision and hearing to normal range
• Work Environment: Minimal exposure to communicable diseases

This Job Description is not a complete statement of all duties and responsibilities comprising the position.