Prior Authorization Nurse Jobs in Springfield, IL

The Authorization Coordinator will be responsible for effectively acquiring Radiation Oncology authorizations, working denied authorizations and submitting appeals as needed. The Authorization Coordinator must be able to handle multiple, simultaneous tasks effectively and efficiently and is expected to demonstrate ENCORE in all communications.

Essential Duties and Responsibilities

• Submit referral, precertification and/or authorization for radiation oncology services from schedules two weeks out and checking back for add ons within 72 hours of exam to positively impact DSO for 100% of patients that require authorization.
• Average time from precertification and/or authorization request notification and submission to approval should not exceed 5 business days
• Review client queues and schedules daily to identify patients requiring authorization per payer requirements.
• Review guidelines to confirm if no auth is required that exam meets medical necessity.
• Communicate with physician/clinical staff on authorization issues and/or pre-certification requirements by the patient's insurance carriers.
• Identify and address denied authorizations to include the appeal process and denial resolution.
• Notify Billing Departments of any special instructions, for example, Skilled Nursing Facility or Inpatients. Demonstrated by <3% error rate on voids and/or rebills for this reason.
• Document accurate authorization activity to reflect work performed in physician/hospital system, billing system, and other systems as needed for reporting and tracking.
• Create relationships at the payer level to assist with initial authorization approval, reduce the need for peer-to-peer, and guarantee the successful reversal of authorization denials.
• Participate in all required meetings with client/personnel, become one of the team.
• Review processes and provides suggestions for process improvements and efficiencies.
• Stay up to date on all CPT/HCPCS/ICD-10 code changes and all payer policy authorization requirements.
• Exhibit ENCORE values.

Other Expectations/Skills

• Self-motivated with the ability to problem solve.
• Customer service focused
• Reliable and extremely trustworthy.
• Ability to maintain confidential and meticulous records.
• Excellent verbal and written communication skills.
• Proficient in Microsoft Office Suite or related software.
• Exceptional organizational skills and attention to detail.
• Ability to learn various software applications
• Superior analytical and technical skills.

ENCORE Values

• Encourage others' success
• New ideas; anticipate problems
• Pick up on problematic client trends quickly and address them efficiently, bringing in management as appropriate.
• Bring at least one idea for a process improvement to the team quarterly.
• Create financial value for our clients
• Interact with client staff and team members to ensure eligibility and authorization requests are completed in a timely and efficient manner.
• Gold Standard: Achieving Authorization goals in the same month 4 out of 6 rolling months
• Authorizations are submitted within 48 hours of notification; based on a monthly average
• Authorization approvals should not exceed a monthly average of 5 business days
• Obtain 90% approval rating from client satisfaction surveys obtained.
• Ownership towards a solution
• When a problem is presented to the team or to management it should be accompanied by at least one feasible solution.
• Reach Life Balance
• Embody a positive approach
• Communication with clients and other RBS divisions should show an "I can" approach.
• Actively engage in department meetings and group conversations with a positive and upbeat attitude.

Requirements

• High School Diploma or equivalent
• Minimum 1 year experience with prior authorization services
• Oncology experience is a plus
• Working knowledge of oncology specific codes and payer rules for commercial, Medicare, Medicare Advantage, and Medicaid plans preferred.
• Knowledge of ICD10, CPT, and HCPCS codes and rules for Tech/Pro/Global and Freestanding/HOPPS coding preferred.

Physical Demands and Work Environment: The physical demands described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the functions.

• Ability to lift/carry up to 25 pounds.
• Ability to sit/stand for long periods of time.
• Good manual dexterity with the ability to perform repetitive hand/wrist motions.
• Requires mastery of complex language, comprehension, reasoning, and analytical skills typically found in mid to high-level work.
• Typical office environment
• Works onsite at client location. May require travel at times to RBS office locations.
• Moderate noise levels

Disclaimer: This job description in no way states or implies that these are the only duties to be performed by the employee(s) of this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities.

The company is an equal opportunity employer, drug-free workplace, and complies with ADA regulations as applicable.