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Prior Authorization Utilization Review Jobs in Washington

UHS

Utilization Review Coordinator

Washington, DC · On-site

$33.60 - $50.40/hr

Six months psychiatric utilization review either for hospital or external review organization ... authorization. Please note that we do not use this information to pre-screen job applicants. EEO ...

UHS

Utilization Review Coordinator

Washington, DC

... authorization. Please note that we do not use this information to pre-screen job applicants. EEO ... Six months psychiatric utilization review either for hospital or external review organization ...

UHS

Utilization Review Coordinator

Washington, DC · On-site

... authorization. Please note that we do not use this information to pre-screen job applicants. EEO ... Six months psychiatric utilization review either for hospital or external review organization ...

MedStar Health

RN Team Lead Utilization Review

Clinton, MD · On-site

$89K - $162K/yr

About the Job Candidate must have acute care Utilization Review experience. Candidate must live in ... Identifies insurance information obtains authorization communicates with financial counseling and ...

MFA

Prior-Authorization Technician- Pharmacy

Arlington, VA · On-site

$23.46 - $30.50/hr

Work with the provider to resolve prior authorization denials, peer-to-peer reviews, and denials * At all times, maintain a courteous interaction with patients, visitors, departments, and medical ...

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Prior Authorization Utilization Review information

What are the key skills and qualifications needed to thrive as a Prior Authorization Utilization Review specialist?

To thrive as a Prior Authorization Utilization Review Specialist, you need a strong understanding of medical terminology, insurance guidelines, and clinical criteria, often supported by a degree in healthcare or nursing and relevant certification (such as RN or LPN). Familiarity with prior authorization software, electronic health record (EHR) systems, and payer portals is typically required. Attention to detail, strong communication skills, and the ability to multitask help professionals excel in this role. These competencies ensure accurate and timely processing of authorizations, reducing delays in patient care and ensuring compliance with payer requirements.

How do I get into a prior authorization utilization review?

To enter a prior authorization utilization review role, candidates typically need a background in healthcare, nursing, or health administration, along with knowledge of insurance policies and medical coding. Relevant certifications such as Certified Professional Coder (CPC) or Certified Utilization Review Professional (CURP) can enhance prospects, and experience with electronic health records (EHR) systems is often required.

What is a Prior Authorization Utilization Review specialist?

A Prior Authorization Utilization Review specialist is a healthcare professional responsible for evaluating medical service requests to ensure they meet specific criteria for approval before services are provided. Their main role is to review clinical information, verify medical necessity, and ensure compliance with insurance policies and guidelines. They act as a liaison between healthcare providers, insurance companies, and patients to facilitate timely and accurate authorization decisions. This process helps to manage healthcare costs and ensure patients receive appropriate care.

What is the difference between Prior Authorization Utilization Review vs Medical Reviewer?

AspectPrior Authorization Utilization ReviewMedical Reviewer
CredentialsLicensed healthcare professionals, often with certifications in utilization reviewLicensed physicians or healthcare providers with clinical expertise
Work EnvironmentInsurance companies, healthcare organizations, or third-party review firmsHospitals, clinics, insurance companies, or consulting firms
Primary FocusAssessing the necessity of procedures or treatments before approvalEvaluating clinical records to determine medical necessity and appropriateness

While both roles involve clinical assessment, Prior Authorization Utilization Review focuses on pre-authorization decisions for treatments, whereas Medical Review involves detailed clinical evaluation of patient records to determine medical necessity. Both require healthcare credentials and are integral to healthcare quality and cost management.

Is prior authorization utilization review a stressful job?

Prior authorization utilization review can be stressful due to the need for accuracy, attention to detail, and meeting strict deadlines. The role often involves reviewing medical documentation and making quick decisions, which can lead to pressure and workload challenges, especially during high-volume periods.

What are some common challenges faced by professionals in Prior Authorization Utilization Review roles, and how can these be managed?

Professionals in Prior Authorization Utilization Review often encounter challenges such as navigating complex insurance policies, managing high volumes of requests, and ensuring timely communication between providers and payers. Staying organized, developing a thorough understanding of payer guidelines, and maintaining clear, consistent communication are key strategies for managing these challenges. Many teams also rely on workflow management tools and regular team huddles to streamline processes and ensure all cases are handled efficiently.
What are popular job titles related to Prior Authorization Utilization Review jobs in Washington? For Prior Authorization Utilization Review jobs in Washington, the most frequently searched job titles are:
What job categories do people searching Prior Authorization Utilization Review jobs in Washington look for? The top searched job categories for Prior Authorization Utilization Review jobs in Washington are:
What cities in Washington are hiring for Prior Authorization Utilization Review jobs? Cities in Washington with the most Prior Authorization Utilization Review job openings:
Prior Authorization Utilization Review jobs near you

Coordinator - Prior Authorization Verification and Eligibility

Luminis Health

Annapolis, MD • On-site

$18.25 - $22.75/hr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 16 days ago

Luminis Health rating

7.9

Company rating: 7.9 out of 10

Based on 54 frontline employees who took The Breakroom Quiz

108th of 887 rated healthcare providers

Job description

Anne Arundel Medical Center
Title: Coordinator, Pre-Authorization Verification & Eligibility (PAVE)
Department: PAVE
Reports To: Supervisor - PAVE
Cost Center/Job Code: 10000-50133-000723
FLSA Status: Non - Exempt
Position Objective:
The PAVE Coordinator is responsible for initiating Pre-Authorization request to the payer for the claims that require approval. This position require communication with payers, patients, physician offices and hospital clinical staff. This position is primarily responsible for pre-certifying procedures ordered by physicians. The PAVE Coordinator will also be responsible monitoring appropriateness and medical necessity and provides necessary information for authorization and continued visits. This individual will confirm pre-certifications that have been obtained or will obtain pre-certifications if needed in addition to conducting quality assurance.
Essential Job Duties:
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  1. Serve as primary resource for LH regarding insurance eligibility; prior authorization process and requirements; collects patient demographic information and coverage information. Advises patients of their financial obligation and collects payments in a courteous and professional manner.
  2. Contacts insurance companies by phone, fax, or online portal to obtain insurance benefits, eligibility, and authorization information;
  3. Updates systems with accurate information obtained; performs quality assurance audits and reports back to leadership opportunities for providing education to patient access
  4. Responsible for communicating to service line partners of situations where rescheduling is necessary, due to lack of authorization or limited benefits and is approved by clinical personnel;
  5. Ensures that proper authorization is in place for inpatient, elective, outpatient, surgical, urgent/emergent services and held responsible for timely notification to payers of the patient's visit to the facility to protect financial standing of the organization. Escalates non-authorized accounts/visits to management;
  6. Ensures all benefits (Copays, Deductibles, Co-Insurance, OOP, LTM), authorizations, pre-certifications, and financial obligations of patients, are documented on account, clearly, accurately, precise, and detailed to ensure expeditious processing of patient accounts and denial prevention.;
  7. Maintains a close working relationship with clinical partners, and ancillary departments to ensure continual open communication between clinical, ancillary, and Patient Access & Patient Financial Services, Surgical Scheduling departments. Case Management, and Utilization Review to facilitate the sending of clinical information in support of the authorization to the payer, as assigned;
  8. Monitors team mailbox, e-mail inbox, faxes, and phone calls responding to all related PAVE account issues, within defined time frames; Adheres to the department accuracy and performance standards.
  9. Contact payer to obtain prior authorization. Gather additional clinical and or coding information, as necessary, in order to obtain prior authorization;

10. Provide standardized documentation within system to identify prior authorization and the criteria surrounding such authorization; Verify that all insurance requirements have been met; Notify patient, Provider's Office, Scheduling and Financial Counselor immediately when insurance coverage is inadequate or has been terminated.
11. Advises providers and their clinical staff when issues arise relating to obtaining prior authorization; educate providers and their clinical staff regarding the prior authorization process.
12. Stay informed and research information regarding insurance criteria for prior authorization; Attend department staff meetings, professional education sessions, complete e-learnings and mandatory training.
13. Performs other duties as assigned by PAVE Leadership.
Educational/Experience Requirements:
  • Minimum two (2+) years of experience in Medical Billing, Hospital Patient Access, or Hospital Business Office in an automated setting.
  • Knowledge of registration, verification, pre-certification, and scheduling procedures.
  • Experience with Medical and Insurance terminology (ICD-10, CPT 4)
  • Minimum of one (1+) year of demonstrated strong analytical skills
  • Proficiency with Microsoft Office and Outlook
  • Excellent verbal and written communication skills.
  • Preferred experience with the Epic Hospital Billing System
  • Associates Degree Accounting, Finance, Business Administration or Healthcare related field preferred
  • Minimum two (2+) years of Revenue Cycle Experience in lieu of degree

Required License/Certifications:
  • 1 or more Certifications preferred:
    • CRCE - Certified Revenue Cycle Executive
    • CRCP- Certified Revenue Cycle Professional
    • CRCS- Certified Revenue Cycle Specialist
    • CHAM - Certified Healthcare Access Manager
    • CHAA- Certified Healthcare Access Associate
    • CHFP- Certified Healthcare Financial Professional
    • CRCR- Certified Revenue Cycle Representative

Working Conditions, Equipment, Physical Demands:
There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.
Physical Demands -
The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.
The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.
Pay Range
$17.50-$26 USD
Luminis Health Benefits Overview:• Medical, Dental, and Vision Insurance
• Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
• Paid Time Off
• Tuition Assistance Benefits
• Employee Referral Bonus Program
• Paid Holidays, Disability, and Life/AD&D for full-time employees
• Wellness Programs
• Employee Assistance Programs and more
*Benefit offerings based on employment status
Opt-in for text notifications!Luminis Health's two-way SMS texting platform lets you receive notifications and messages from our Talent Acquisition team directly on your phone.
To enable this feature, select "yes" when asked to "opt-in to receive text messages" and to "Receive updates from a recruiter about this job via SMS" when completing your application. Once you are opted in, you can easily opt-out at any time. Standard text messaging rates may apply based on the candidate's mobile carrier plan. Luminis Health is not responsible for any charges incurred by the recipient. Candidates are encouraged to review their mobile carrier's plan for applicable text messaging rates and usage charges.

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