Prior-Authorization Spec; BMG

Overview

Reports to the VP Patient Access responsibilities include evaluating designated referred services for authorization needs based on government and commercial payor requirements. Disseminating all clinical and coding supporting documentation to effectively complete the authorization process to ensure appropriate reimbursement. In addition, this position provides exceptional customer service during every encounter with patients, families, visitors and BMG associates by communicating with empathy and clarity regarding the details of the next step in care for the customer.

• MISSION: We deliver outstanding care, inspire health, and connect with heart.
• VALUES: Trust. Respect. Integrity. Compassion.
• SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

• Serving as primary contact and resource for all designated prior authorization needs.
• Identifying, collecting, and coordinating clinical documentation to support the qualification of ordered services.
• Evaluating orders for insurance coverage and authorization requirements.
• Ensuring carrier process requirements are met within contracted guidelines and timeliness.
• Ensuring proper testing is done and using tools in accordance with the provider s desire and the testing criteria and guidelines including both insurance and modality ordering guidelines.
• Reviewing and complying with additional requests.
• Validating completed authorizations to ensure the authorization corresponds with ordered service, code, time frame and provider.
• Supporting the appeal process by communicating and coordinating resolution expectations with provider and authorization agent.
• Maintaining standardized records to allow for effective coordinating, tracking and reporting of department actions and metrics.
• Advocating for the customer by recognizing when to dispute a non-desirable outcome regarding PA approval and disputing/negotiating, when necessary, on behalf of the organization and the customer for a positive prior authorization outcome.
• Providing exceptional customer-centric service during every encounter with patients, families, and associates.
• Using critical thinking to make decisions, identify problems, create solutions and help implement change; escalate concerns when necessary.
• Participating in performance improvement by following established work systems and communicating problems to supervisor or management; prioritizing work effectively; working at a fast pace with accuracy.
• Understanding the flow and rhythm of each task and connecting resulting care in a convenient, connected manner.
• Using multiple software platforms (multiple EMR s, insurance websites, referral database, scheduling software, etc.) to conduct tasks for patient care.

• Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by assisting others and accepting additional duties.
• Enhancing professional growth through in-service meetings and educational programs as approved.
• Maintaining up-to-date knowledge and staying abreast of changes and updates as they occur (Insurance, Department and Processes changes).

Associate complies with the following organizational requirements:

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department-specific education within established time frames.
• Completes annual employee health requirements within established time frames.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

• Leverage innovation everywhere.
• Cultivate human talent.
• Embrace performance improvement.
• Build greatness through accountability.
• Use information to improve and advance.
• Communicate clearly and continuously.

• The knowledge, skills and abilities as indicated are normally acquired through the successful completion of an Associate s Degree in Business or Health Care related field and one year medical authorization or related experience; or, in lieu of a degree, completion of a high school diploma or equivalent and three years medical authorization or related experience. Successful completion of an approved Medical Assistant Program with successful completion of the Certification Exam or equivalent medical office experience is preferred.
  
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