Description

Lexington Regional Health Center

Title: Prior Authorization Specialist

Effective Date: November 29, 2023

Supervisor: Informatics System Coordinator

Department: Nursing

FLSA Status: Non-Exempt

Principle duties and responsibilities

1. Contacts insurance carriers to verify patient’s insurance eligibility, benefits & medical necessity.
2. Obtains clinical information (including but not limited to medical history, relevant labs and diagnostic testing) necessary to complete the Prior Authorization.
3. Confirm accuracy of Current Procedural Terminology (CPT) and standards as defined by the current International Classification of Diseases (ICD).
4. Ensure the provider order includes a payable diagnosis code according to the insurance company.
5. Views the insurance companies’ guidelines for medical necessity by navigating the websites.
6. Verifies that the patient meets the medical necessity guidelines as outlined by the patient’s insurance company.
7. Requests additional required documentation from providers.
8. Initiates, tracks and obtains pre-authorization from third-party payers within 48 hours of receiving the order.
9. Documents the case status, actions and outcomes in the patient’s Electronic Medical Record.
10. Communicates any insurance changes or trends among the team.
11. Maintains a level of productivity as defined by the department director.
12. Prioritizes incoming authorization requests according to urgency.
13. Manages multiple authorization requests at once.
14. Schedules Peer to Peer (P2P) reviews for the providers as needed.
15. Initiates appeals for denied authorizations.
16. Responds to clinic and provider questions regarding payer medical policy guidelines.
17. Contacts patients to discuss authorization status and schedules a Pre-Admission visit with the Nurse Educator for all surgery cases.
18. Serves as a liaison with patients and their families, supports departments, etc. to adequately plan for the patient’s care.
19. Communicates scheduling and authorization concerns to supervisor.
20. Participates in patient care activities that could include blood exposure and risk to bloodborne pathogens (eg: lacerations, handling of blood-contaminated specimens, etc.)
21. Responsible for ensuring the environment meets appropriate governing body standards.
22. Ensure patients and visitors follow current infection control guidelines.
23. Maintains patient and staff safety through the use of patient safety tools (TeamSTEPPS, Just Culture, etc.).
24. Serves on various committees as assigned. 
25. Regular attendance at the assigned work location is required. May have the potential to transition to a work from home position based on the needs of the organization after on-site orientation and training has been established.
26. Performs all other duties as assigned.

Minimum knowledge, skills, and abilities

1. Ability to read, write and use basic computer and office equipment skills as is typically acquired through the completion of a high school diploma or equivalent.
2. Experience in a hospital, physician’s office or authorization department is preferred.
3. Advanced communication skills to respond to inquiries from Insurance companies and Workers’ Compensation companies.
4. Understanding of the importance of authorization and its direct impact on the facility’s Revenue Cycle.
5. Understanding of payer Medical Policy Guidelines & utilizing theses guidelines to manage authorizations effectively.
6. Basic understanding of Human Anatomy and Medical Terminology.
7. Detail oriented with above average organizational skills.
8. Ability to multi-task, expect interruptions and remain focused while managing a high-volume, time-sensitive workload.
9. Must be willing to learn the facility’s Electronic Medical Record.
10. Ability to maintain strict confidentiality with regard to protected and sensitive information.
11. Ability to complete reports and correspondence at a professional level.
12. Ability to immediately respond to common inquires and complaints from patients, employees, and regulatory agencies in collaboration with supervisor and administration.
13. Ability to effectively communicate with individuals from diverse backgrounds.
14. Successful completion of required knowledge and training of standard precaution and transmission protocols and when to apply during principle duties and responsibilities. 

Working conditions

1. Works in a normal office work environment with little exposure to excessive noise, dust, temperature etc.
2. Sitting, walking, and/or standing for up to 90% of work time when doing Utilization Review, Preauthorizing Orthopedic and Urology surgeries and Mental Health Assessments, etc. Up to 20% of work time may push items weighing up to 50 pounds when assisting nursing staff if needed. 
3. Exposure to chemicals and other hazards related to patient care. Appropriate safety precautions, such as safety glasses, gloves, etc. must be used to minimize risk of injury.
4. Direct exposure to body substances during patient care activities and on contaminated surfaces such as patient equipment.

Management responsibilities

1. None

Job description statements are intended to describe the general nature and level of work being performed by employees assigned to this job title. They are not intended to be a complete list of all responsibilities, duties and skills required.