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

* Contacts insurance carriers to verify patient's insurance eligibility, benefits & medical necessity.

* Obtains clinical information (including but not limited to medical history, relevant labs and diagnostic testing) necessary to complete the Prior Authorization.

* Confirm accuracy of Current Procedural Terminology (CPT) and standards as defined by the current International Classification of Diseases (ICD).

* Ensure the provider order includes a payable diagnosis code according to the insurance company.

* Views the insurance companies' guidelines for medical necessity by navigating the websites.

* Verifies that the patient meets the medical necessity guidelines as outlined by the patient's insurance company.

* Requests additional required documentation from providers.

* Initiates, tracks and obtains pre-authorization from third-party payers within 48 hours of receiving the order.

* Documents the case status, actions and outcomes in the patient's Electronic Medical Record.

* Communicates any insurance changes or trends among the team.

* Maintains a level of productivity as defined by the department director.

* Prioritizes incoming authorization requests according to urgency.

* Manages multiple authorization requests at once.

* Schedules Peer to Peer (P2P) reviews for the providers as needed.

* Initiates appeals for denied authorizations.

* Responds to clinic and provider questions regarding payer medical policy guidelines.

* Contacts patients to discuss authorization status and schedules a Pre-Admission visit with the Nurse Educator for all surgery cases.

* Serves as a liaison with patients and their families, supports departments, etc. to adequately plan for the patient's care.

* Communicates scheduling and authorization concerns to supervisor.

* Participates in patient care activities that could include blood exposure and risk to bloodborne pathogens (eg: lacerations, handling of blood-contaminated specimens, etc.)

* Responsible for ensuring the environment meets appropriate governing body standards.

* Ensure patients and visitors follow current infection control guidelines.

* Maintains patient and staff safety through the use of patient safety tools (TeamSTEPPS, Just Culture, etc.).

* Serves on various committees as assigned.

* 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.

* Performs all other duties as assigned.

Minimum knowledge, skills, and abilities

* 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.

* Experience in a hospital, physician's office or authorization department is preferred.

* Advanced communication skills to respond to inquiries from Insurance companies and Workers' Compensation companies.

* Understanding of the importance of authorization and its direct impact on the facility's Revenue Cycle.

* Understanding of payer Medical Policy Guidelines & utilizing theses guidelines to manage authorizations effectively.

* Basic understanding of Human Anatomy and Medical Terminology.

* Detail oriented with above average organizational skills.

* Ability to multi-task, expect interruptions and remain focused while managing a high-volume, time-sensitive workload.

* Must be willing to learn the facility's Electronic Medical Record.

* Ability to maintain strict confidentiality with regard to protected and sensitive information.

* Ability to complete reports and correspondence at a professional level.

* Ability to immediately respond to common inquires and complaints from patients, employees, and regulatory agencies in collaboration with supervisor and administration.

* Ability to effectively communicate with individuals from diverse backgrounds.

* Successful completion of required knowledge and training of standard precaution and transmission protocols and when to apply during principle duties and responsibilities.

Working conditions

* Works in a normal office work environment with little exposure to excessive noise, dust, temperature etc.

* 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.

* 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.

* Direct exposure to body substances during patient care activities and on contaminated surfaces such as patient equipment.

Management responsibilities

* 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.