Description

JOB SUMMARY

The Prior Authorization Specialist is responsible for working with third party payers and providers to ensuring physician services that require pre-authorizations are completed in an accurate and timely manner. Responsible for ensuring payment of tests and procedures prior to administration of test and/or procedure. Must also performing insurance and benefit verification as a part of obtaining prior authorizations for services provided to patients.

JOB RESPONSIBILITIES

• Review, evaluate, verify and process assigned clinic pre-certification requests for Inpatient, Outpatient and other clinic procedures performed by facility providers.

• Contact insurance companies for pre-certification, at least seven days prior to the patient's scheduled procedure.

• Apply basic coding knowledge and proficiency in medical terminology to translate orders to appropriate CPT and Diagnosis information required to provide to third party payers for prior authorization.

• Work with providers to coordinate peer-to-peer review with third party payers or find suitable alternatives to tests or procedures that do not meet prior authorization requirements.

• Work with third party payers to obtain all necessary information to complete a prior authorization, such as reviewing medical document for past procedures, therapies, tests or other clinical services.

• Enter all prior authorization information into the scheduling and billing system.

• Assist Clinics in obtaining prior authorizations for emergency admits and for patients needing same day clinic visit/hospital admit/procedure.

• Confirm all necessary information needed to properly perform and identify billing information needed to maintain compliance with institutional, state and federal practices.

• Verify patient eligibility and prior authorization requirements through On-line verification software or by telephone and follow up with third party payers within 0-48 hours of request.

• Maintain open line of communication with clinic personnel.

• Assists in training new employees of the prior authorizations team.

• Provide Team Coverage.

• Performs other tasks as assigned by supervisor.

Requirements

MINIMUM EDUCATION & EXPERIENCE

• High school diploma or GED required; college preparation preferred.

• 2-5 years’ experience in a healthcare prior authorization or insurance authorization role.

• Basic coding knowledge, understanding of CPT and ICD-10, and proficiency in medical terminology.

KNOWLEDGE, SKILLS, & ABILITIES

• Thorough knowledge of the healthcare revenue cycle including ICD-9 and CPT coding, and CMS guidelines

• Working knowledge of electronic health records and practice management systems

• Knowledge of current payer precertification processes and guidelines

• Ability to multi-task and function effectively in a dynamic and fast-paced environment

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