Prior Authorization Specialist

Prior Authorization Specialist

Full-time

I. Job Summary / Job Purpose

The Prior Authorization Specialist is responsible for obtaining appropriate insurance verification, prior approval and all authorization requirements prior to a patient's arrival for a procedure. To perform authorization activities of inpatient, outpatient and emergency department patients, denial management and all revenue functions. Need to demonstrate, through actions, a consistent performance standard of excellence to which all work is to conform. The expertise of the Authorization Specialist shall include working knowledge in the area of authorization related activities including pre-authorizations, notifications, edits, denials, etc. The Authorization Specialist shall demonstrate the philosophy and core values of EngageMED in the performance of duties.

II. Key Responsibilities

Review demographic, billing and insurance information for accuracy.

Verify insurance eligibility. Make necessary corrections.

Obtain Precertification and authorization.

Communicate detailed policy benefits to patients.

Respond to phone calls and correspondence relating to patient accounts.

Professional and Positive communication skills internally and externally

Work under pressure and resolve problems

Ability to navigate insurance carrier websites

Reviews and interprets medical record documentation for patient history, diagnosis, and previous treatment plans to pre-authorize insurance plan determined procedures to avoid financial penalties to patient, provider and facility.

Utilizes payor-specific approved criteria or regulations to determine medical necessity or the clinical appropriateness for inpatient admissions, outpatient facility, office services, and drugs in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury, or disease.

Provides referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive nonclinical administrative time required of providers. Submits pertinent demographic and supporting clinical data to payor to request approval for services being rendered

III. EngageMED Core Expectations

At EngageMED, we expect all our employees to live the values of Reverence, Integrity, Compassion and Excellence at work by:

Honoring and caring for the dignity of all persons in mind, body, and spirit

Ensuring the highest quality of care for those we serve

Working together as a team to achieve our goals

Improving continuously by listening, and asking for and responding to feedback

Seeking new and better ways to meet the needs of those we serve

Using our resources wisely

Understanding how each of our roles contributes to the success of EngageMED.

IV. Core Job Competencies

Core EngageMED Behaviors: The following behaviors have been identified as critical to all staff roles at EngageMED:

Teamwork Orientation: works cooperatively & collaboratively with others toward the accomplishment of shared goals.

Service Orientation: desire to serve and focus one’s efforts on discovering and meeting the needs of internal and external customers.

Achieves Results: reflects a drive to achieve and outperform. Continuously looking for improvements. Accepts responsibility for actions and results.

Learning and Growth: has a commitment to continuous professional and organizational learning

Communication: practices attentive and active listening and can restate opinions of others; communicates messages in a way that has the desired effect.

Role-Specific Behaviors: these additional behaviors are necessary in the role:

Proficient knowledge of clinic referral and scheduling processes and billing/authorization requirements.

Knowledge of federal and state pay requirements, including Medicare, DSHS, HMO/PPO Contracts.

Ability to communicate effectively and to maintain strict confidentiality.

Ability to respond to people and issues promptly and appropriately, to resolve problems.

A team player who handles multiple projects simultaneously in a fast-paced environment.

Possess a strong work ethic and a high level of professionalism.

Skills, Knowledge or Abilities critical to this role:

Language Ability: Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to common inquiries or complaints from groups of managers, clients, customers, and the general public.

Math Ability: Ability to add, subtract, multiply and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Reasoning Ability: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Computer Skills: Must be proficient with the Microsoft Office Suite, Internet navigation, database management, desktop publishing, spreadsheet, and graphic presentation packages.