Prior Authorization Specialist
: Job Details :

Description:Supervisory Report: Nurse ManagerWage Classification: Non-ExemptJob Summary:The Prior Authorization Specialist is responsible for all aspects of the prior authorization process. Responsibilities include obtaining pre-certifications and pre-authorizations for procedures and medications, scheduling appointments for outpatient testing with other providers, coordinating patients' appointments/orders, collecting all the necessary documentation, contacting the patient for additional information and completion of the required prior authorization. The incumbent is responsible for documenting the appropriate information in the patient's record.Essential Responsibilities:The following duties are not intended to serve as a comprehensive list of all duties performed by all associates in this classification. Listed are duties intended to provide a representative summary of the major duties and responsibilities. Incumbent(s) may not be required to perform all duties listed and may be required to perform additional, position-specific duties.* Greet and assist patients professionally and courteously in person or on the phone to provide each patient assistance with insurance authorizations.* Appropriately prioritize workload to ensure the most urgent cases are handled in a timely manner according to urgency.* Obtain authorization via payer website or by phone and follow up regularly on pending cases.* Maintain individual payer files to include up to date requirements needed to successfully obtain authorizations.* Communicate with patients, clinical partners, patient service representatives, and others as necessary to facilitate authorization process.* Initiate appeals for denied authorizations at the provider's request.* Coordinate and provide information to the review organization (payer) including medical information and/or letter of medical necessity for determination of benefits.* Answer providers, staff, and patient questions surrounding insurance authorization requirements. respond to clinic questions regarding payer medical policy guidelines.* Confirm accuracy of CPT and ICD-10 diagnoses in the procedure order.* Contact patients to discuss authorization status.* Document clearly all communications and contacts with providers and personnel in standardized documentation requirements, including proper format.* Review and update, as necessary, patient information including patient's demographics, emergency contact and insurance information in the Practice Management system.* Monitor and retrieve voice messages daily from appropriate voicemail boxes.* Other duties as assigned.Requirements:To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.Education and/or Experience:* High school diploma or GED required* Minimum of two years' experience in medical billing/pre-authorization or insurance verification with demonstrated knowledge of health insurance plans including: Medicaid, Medicaid Managed Care, Medicare, Medicare Advantage Care Plans, HMO's and PPO's* Computer proficiency with Microsoft Outlook, Word, Excel required. Prior experience with electronic medical record preferredLanguage Skills:Bilingual (English/Spanish) highly preferred)Performance Requirements:Knowledge:* Demonstrate and apply knowledge of medical terminology* Understanding of payer medical policy guidelines to manage authorizations effectively* Proficient use of CPT and ICD-10 codes* High proficiency of general medical office procedures* Knowledge of online insurance eligibility systems* Knowledge of medical center practices* Knowledge of EMR system, medical record documentation requirements and state/federal laws related to the release of health care information* Knowledge of HIPAA regulationsSkills:* Skill in solving practical problems* Excellent phone etiquette* Excellent customer serviceAbilities:* Ability to accept, interpret and implement orders from the qualified professionals on the team* Ability to communicate effectively and develop rapport with patients and families to facilitate implementation of a care plan* Ability to remain calm when emergencies occur* Ability to manage time effectively* Maintain a level of productivity suitable for the departmentEquipment Operated:Wide range of standard office equipment. Computer use, and proficiency required.Work Environment:Cubicle area in small call center office, medical exam/treatment rooms and medical offices in Health Center. Controlled lighting, air quality, and temperature settings. Environmental hazards may be unpredictable including exposure to communicable diseases and biohazards.Mental/Physical Requirements:Involves standing, walking, kneeling, bending, grasping, manipulating and squatting and lifting (up to 50 pounds). Walking or standing may be more than two (2) hours per day. Must be able to work in a standard medical office setting including use of a computer, and standard office equipment. Must have ability to read computer screens, printed materials and hearing and speech to communicate in person as well as over the phone. Must be able to attend meetings at various sites when required. Stress can be triggered by workload.GENERAL INFORMATION:* La Red Health Center, Inc. is a private not for profit corporation serving Sussex County, Delaware.* The administrative office is located at 21444 Carmean Way in Georgetown, Delaware.* The associate should recognize that La Red Health Center is committed to ensuring that we follow fundamental principles of ethical business conduct and adhere to all applicable laws and regulations to protect La Red Health Center's good name and reputation.* In that all associates contribute to the overall growth and development of La Red Health Center, Inc., it is occasionally necessary for associates to perform tasks that are not specifically indicated in their position descriptions.