Prior Authorization Specialist - Business Office (22371)

POSITION SUMMARY:

Responsible for initiating and obtaining prior authorizations for procedures and medications, scheduling appointments for outpatient services; coordinates patient appointments/ orders. This position primarily works remotely.

KNOWLEDGE, SKILLS, AND ABILITIES

• Ability to maintain effective working relationships with coworkers, patients, medical staff, insurance companies and the public.
• Ability to take charge while remaining approachable, respectful and understanding.
• Ability to communicate clearly and effectively in person, writing or by phone.
• Ability to adapt to change.
• Ability to organize and prioritize tasks.
• Ability to operate computers, telephones, and other office equipment.
• Ability to react calmly and competently in emergency situations.
• Knowledge and understanding of insurance policies and benefits.
• Knowledge of medical terminology.
• Knowledge and understanding of insurance claim processing.
• Strong organizational skills.

DUTIES & RESPONSIBILITIES:

• Conduct Pre-authorizations with insurance companies for a multitude of different services.
• Discuss with patients’ necessary regulations in regard to Medicare billing and other non-covered procedures.
• Promote and maintain confidentiality.
• Inform supervisor of potential issues with insurance or patients.
• Coordinate and follows the established preauthorization review process for outpatient and inpatient services.
• Timely review of prior authorization requests, both inpatient and outpatient.
• Surgical/Diagnostic procedures/Therapies/DME/Infusions
• Medication prior authorization requests
• Other Prior Authorizations as the needs arise
• Perform telephonic or electronic review of prior authorization request for appropriate care setting, following guidelines and policies and forward requests to appropriate departments.
• Complete medical necessity and level of care reviews for requested services using clinical judgment. Refer to medical staff for other determinations as needed.
• Provide clinical knowledge and act as clinical resource to non-clinical team.
• Schedule patient appointments in timely manner once prior authorization has been approved. This includes contacting the patient with the appointment information and ensuring the patient receives the appropriate education for the scheduled event.
• Provides accurate documentation in patient EMR and reporting to other agencies (i.e. health department).
• Maintains accountability of patient records.
• Demonstrates appropriateness in meeting objectives in age-specifics.
• Performs other duties as assigned.

QUALIFICATIONS and EXPERIERNCE:

High school diploma or GED. 

Business healthcare degree or 2 years’ experience working in a medical office or insurance company.

Heartsaver CPR Certified (obtain upon employment)