Prior Authorization Specialist

Description

• Obtains pre-authorizations/pre-certification per payer requirements for services and ensures authorization information is documented appropriately.
• Verifies physician orders are complete, determines CPT, HCPCS and ICD-10 codes for proper authorization.
• Ability to understand and communicate insurance co-pays, deductibles, co-insurances, and out-of-pocket expenses for point of service collections.
• Communication is maintained with providers, clinical staff, and patients in relationship to authorization status.
• Remains current with insurance requirements for pre-authorization and provides education within the departments and clinics on changes.
• Keep informed of changes in the authorization process and insurance policies
• Aid team members in maintaining turnaround times.
• Account for internal control responsibilities in line with the department objectives.
• Ability to handle Protected Health Information in a manner consistent with the Health Insurance Portability and Accountability Act (HIPAA).
• Answer questions and offer other information, as requested, to provide patient-focused service and a positive impression of the organization.
• Other duties as assigned by the supervisor or manager.

• Obtains pre-authorizations/pre-certification per payer requirements for services and ensures authorization information is documented appropriately.
• Verifies physician orders are complete, determines CPT, HCPCS and ICD-10 codes for proper authorization.
• Ability to understand and communicate insurance co-pays, deductibles, co-insurances, and out-of-pocket expenses for point of service collections.
• Communication is maintained with providers, clinical staff, and patients in relationship to authorization status.
• Remains current with insurance requirements for pre-authorization and provides education within the departments and clinics on changes.
• Keep informed of changes in the authorization process and insurance policies
• Aid team members in maintaining turnaround times.
• Account for internal control responsibilities in line with the department objectives.
• Ability to handle Protected Health Information in a manner consistent with the Health Insurance Portability and Accountability Act (HIPAA).
• Answer questions and offer other information, as requested, to provide patient-focused service and a positive impression of the organization.
• Other duties as assigned by the supervisor or manager.

• High school diploma or equivalent
• Medical Assistant or higher

• 3-5 years of experience working in a hospital, doctor’s office, or pharmacy setting with knowledge of procedures and/or medication authorization experienced required.
• 1-2 years procedure and/or medication authorization experience preferred.

• Regular and reliable attendance is an essential function of the job.

• Knowledge of CPT, HCPCS, and ICD-10 codes.
• Knowledge of medical terminology and departmental services.

• Knowledge of CPT, HCPCS, and ICD-10 codes.
• Knowledge of medical terminology and departmental services.

• Basic computer skills (Microsoft Office Suite).
• Basic problem-solving skills.
• Possess pleasant and effective written, verbal, and telephone communication skills.
• Must possess excellent time management and organizational skills.
• Must possess multi-tasking skills.

• Ability to maintain a professional demeanor during stressful situations.
• Ability to solve conflict.
• Ability to use multi-line phone system, including transferring calls and paging.
• Prevents, calms, or defuses irate callers and patients by working with them to identify concerns and properly directs calls.

• Standard office equipment including computers, fax machines, copiers, printers, telephones, etc.

• Position is in a well-lit office environment.

• Involves sitting approximately 90 percent of the day, walking or standing the remainder.