Department: Infusionist

Reports To: Manager, Rheumatology & Infusion

FLSA: Non-Exempt

Job Purpose:

The Prior Authorization Specialist is responsible for obtaining prior authorizations for all procedural orders by successfully completing the authorization process with all commercial payers, and specialty pharmacies. The Rheumatology Prior Authorization Specialist is also responsible for managing the Copay and Patient Assistance programs. Will be expected to work closely with the Rheumatology Prior Authorization Nurse to ensure timely, high-quality, cost-effective care.

Primary Duties and Responsibilities:

• Expertise in conjunction with established medical criteria, to establish patients’ eligibility and benefit coverage.

• Collects existing and new patient insurance information for insurance verification purposes.

• Verifies infusion order in the medical chart.

• Prioritize incoming authorization requests and verification of benefits according to urgency

• Utilizes technology and resources (systems, telephones, etc.) to appropriately complete prior authorization activities.

• Effectively and accurately communicates and documents prior authorization process to patients, providers, and department leadership.

• Effectively and accurately communicates and documents Copay assistance and Patient Assistance eligibility to patients. Completing and submitting all necessary documents.

• Interact with providers to obtain additional clinical information and participate in the development and modification of medical necessity criteria.

• Follows up on pending referrals, missing clinicals, and other items needed for criteria completion within a timely manner.

• Verifies patient has completed necessary labs prior to infusion.

• Handles infusion co-payments; signs patients up if eligible, contacts drug companies, and obtains and handles reimbursement.

• Assists the RN Prior Auth Nurse with the appeal process when a medication is denied. Notifies department leadership of denials.

• Collaborates with Infusion Staff regarding patient treatments and schedule.

• Maintains and updates patient medical records.

• Answers incoming calls in a friendly and professional manner.

• Other duties as assigned.

Competencies:

• Service: We align our actions and decision making with the organization’s guiding platform keeping our patients at the center of all we do.

• Change Agent: We support and contribute to positive change in the organization.

• Communication and Interpersonal Relations: We communicate honestly and with compassion to build connections with our patients and each other.

• Effectiveness: We take ownership of work, doing the right thing for our customer and doing it well.

Organizational Culture:

All OrthoIllinois employees focus on service by putting the mission, vision, and value statements into practice and using the guiding principles of Compassion, Respect, Trust, Integrity, Innovation, Education Fiscal Responsibility, Practice Independence, Accountability, and Empowerment to direct their interactions and decision making. Employees promote and model the service standards to create lasting impressions, extraordinary moments, exceptional on-stage experiences, and meaningful and compassionate connections.

Education and Experience Requirements:

• High School Diploma or GED

• 2 years Prior Authorization and/or Utilization Review experience preferred.

• 2 years’ experience in a medical related field required

• Basic understanding of Rheumatology specific diagnosis

• Proficient use of CPT and ICD-10 codes

• Excellent computer skills including Excel, Word, and Internet use

• Working knowledge of medical insurance, commercial/Medicare reimbursement, and managed care preferred.

• Familiarity with claim management systems preferred.

• Excellent interpersonal, communication, and organizational skills required.

• Ability to prioritize, multi-task, and problem solve required.

Environmental/Working Conditions:

Working environment is in an office/clinic setting.

Physical/Mental Demands:

• Sit for extended periods of time

• Lifting, carrying and/or moving objects up to 20 pounds in a manner consistent with most office environments

• Finger dexterity for typing on a keyboard and using a mouse for extended periods of time.

• Vision (e.g., depth perception, color vision, strong vision up close); hearing (e.g., high pitch sounds, soft or distant sounds)

This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve