Description

Job Title: Prior Authorization Representative 

Department: Clinic

Position Summary:

Performs general clerical and office support duties to ensure the effectiveness and efficiency of the service. Monitors proper insurance pre-authorizations and Medicaid referrals for tests/procedures performed at WRH.

Requirements

Education/Experience:

Must have good human relations and communication skills. Must be able to follow procedures and instructions given by the licensed nurse. Must be able to acquire a basic knowledge of patient care principles, medical terminology and equipment within the assigned service area.

Required Credentials (Licensure, Certification, or Registration):

Employment Variables:

Care is delivered to clinic patients of all ages. Work hours vary according to clinic schedules. 

Initial Tuberculosis (TB) test and drug screening is required by Winner Regional Health. Rubella titer will also be drawn upon hire and immunization is required if no past exposure or indication of immunization.

Required to wear name tag provided by WRH and to follow the dress code of WRH.

Job Knowledge and Skills:

Ability to read, write, speak and understand the English language and follow oral or written instruction. Excellent oral and written communication skills, work with customers and co-workers in a professional manner. 

Direct Supervisor:

Clinic Director

PI PART II: CODE OF CONDUCT STDS OF BEHAVIOR (Refer to Standards of Behavior Booklet

Honesty

We will do the right thing at all times, even if it is difficult, maintaining strong, ethical practices. We protect the confidentiality of others, including patients, staff and the facility as a whole. We will take responsibility for our actions.

Expertise

We will demonstrate superior judgment, training and skill, at all times, demonstrating professionalism while doing so. We will perform all aspects of our job to the best of our ability, utilizing all resources and tools available.

Approachability

We will be non-judgmental, friendly, and open and willing to listen to everyone we come into contact with while performing our duties. We are humble and learn from others.

Respect

We will be understanding and sensitive to others’ feelings; caring and responding in a manner that sets them at ease, keeping the situation in perspective without minimizing others’ feelings or reactions. We will listen to others with full attention in a sincere, civil fashion, being careful not to be judgmental of the speaker. We maintain composure when facing conflict and avoid jumping to conclusions and defaming another’s name.

Teamwork

We willingly work together with a common approach, trusting and supporting members of our organization, using our skills and resources, sharing information to achieve a common aim.

P PART III: ESSENTIAL FUNCTIONSART III: ESSENTIAL FUNCTIONS

Essential functions are critical or fundamental to the performance of the job. They are the major functions for which the person in the job is held accountable. Following are the essential functions of the job, along with the corresponding performance standards.

Care of Patient

Assists with the gathering of basic objective and subjective data, identified by the licensed nurse, from observations and interviews. 

Has the ability to identify basic signs and symptoms of deviations from normal health status and provides basic information which licensed nurses use in the identification of problems and needs.

Participates in the giving of direct patient care by assisting with activities of daily living, providing comfort measures and emotional support to patients whose condition is stable and predictable, documenting and communicating completion of delegated nursing interventions and patient responses and seeks guidance and direction when appropriate.

Contributes to the evaluation by documenting and communicating patient responses and assists with collecting data.

Prepares work areas and equipment to facilitate the licensed nurse/provider in performing patient care.

Performs general clerical and office support duties to ensure the effectiveness and efficiency of the service.

Assists with transportation of patients to other areas of facility as needed (Radiology, Laboratory, etc)

Assists with insurance and DOT screenings including breath alcohol, paternity testing, urine drug screen by obtaining blood specimens from patients, preparing blood and urine samples for analysis.

Performs EKG testing by attaching electrodes to specified body areas, activates electrocardiograph and manipulates switches to record pulse from electrodes.

Monitors proper insurance pre-authorizations and Medicaid referrals for tests/procedures performed at WRH.

Communication

Communicates changes in patient status with provider.

Gives pertinent and timely report to co-workers.

Promotes and assists others to practice safe work habits; identifies and reports health and safety hazards; and offers suggestions and participates in corrective action.

Communicates with team members in a professional and respectful manner.

Documents accurately, thoroughly and legibly.

Professional Attitude

Respects physical privacy of patient.

Functions independently, recognizing own expertise as well as available resources.

Recognizes own limitations and seeks assistance as needed.

Policies and Procedures

Complies with department and organizational policies and procedures related to emergency/crisis intervention, confidentiality, safety practices, reporting of incidents, risk management procedures and mandated reporting policies.

PART IV: COMPLIANCERT IV: COMPLIANCE

Compliance

Must comply with the Corporate Compliance Policy and all laws, rules, regulations and standards of conduct relating to the position. 

The employee has a duty to report any suspected violations of the law or the standards of conduct to the Compliance Officer or the Chief Executive Officer.

PART V: PHYSICAL AND MENTAL REQUIREMENTSRT V: PHYSICAL AND MENTAL REQUIREMENTS

General Activity

In a regular workday, employee may:

Sit: 5/8 Hours at a time; up to 1-2 Hours during the day

Stand: 1/8 Hours at a time; up to 1-6 Hours during the day

Walk: .25 Hours at a time; up to 5-6 Hours during the day

Motion 

Employee is required: (In terms of a regular workday, "Occasionally" equals 1% to 33%, "Frequently" 34% to 66%, "Continuously", greater than 67%.)

Bend/Stoop

Kneel, Duration 30 sec

Squat

Balance

Crawl, Distance

Twist

Climb, Height

Keyboarding/Mousing

Frequently

Reach above shoulder level

Physical Demand

Employee’s job requires he/she carry and lift loads from the floor, from 12 inches from the floor, to shoulder height and overhead. Employee’s job requires a pushing/pulling force to move a load (not the weight of the load).

Physical Demand Classification:

Carrying/lifting weight and pushing/pulling force:

Light-Medium

Occasionally

35 lbs. 

Frequently

10 lbs.

Constantly

Negligible 

Sensory Requirements:

Yes/No

Explanation (if Yes)

Speech

Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly. 

Communicates with staff and patients on phone or in person. Responds to patient’s concerns and questions.

Vision (VDT)

Are there specific vision requirements for the job?

Must be able to read numbers and names. Must be able to distinguish colors and view a computer screen.

Hearing

Ability to receive detailed information through oral communications, and to make fine discriminations in sound; i.e., making fine adjustments on machine parts, using a telephone, taking blood pressures. 

Vital communication with other clinic staff and patients directly or via telephone.

Environmental Factors

Yes/No

Explanation (if Yes)

Working on unprotected heights

Being around moving machinery

Exposure to marked changes in temperature and humidity

No

Driving automotive equipment

No

Wearing personal protective equipment

Yes

Exposed to body fluids and waste

Exposure to atmospheric conditions (i.e. fumes, dust, odors, mists, gases, or poor ventilation)

No

Exposure to extreme noise or vibration

Exposure to blood, body fluids and waste

Yes

Exposed to body fluids and waste

Exposure to radiation

No

Exposure to other hazards (i.e. mechanical, electrical, burns, or explosives)

Yes

Exposed to needles and hazardous cleaning solutions

Emotional/Psychological Factors

Yes/No

Explanation (if Yes)

Stress: Exposed to stressful situations

Must be able to effectively deal with concerns of upset patients or other clinic staff.

Concentration: Must be able to concentrate on work tasks amidst distractions.

There are many phone and personal interruptions throughout the work day.

Must exert self-control. 

Must be able to display control and confidence under stress.