Pre Authorization Representative - Case Mgmt

MAIN FUNCTION:

Works within a team environment pre-authorizing exams for various hospital services. This position will require a degree of complexity and prior anatomy education.

DUTIES AND RESPONSIBILITIES:

COMMUNICATION:

1. Promptly answers the telephone in a professional and courteous manner.

2. Demonstrates the knowledge and ability to utilize various computer networks and telephone applications to procure pre-authorizations for patients.

3. Demonstrates the ability to complete pre-authorizations in a timely manner.

4. Demonstrates the ability to communicate courteously and effectively with internal and external customers.

5. Demonstrates an understanding of both CPT , ICD9 and medical terminology.

6. Demonstrates the ability to check appointment schedules daily to ensure that all admissions and procedures have been approved (pre-authorized) by the insurance carrier.

CLERICAL:

7. Demonstrates insurance knowledge.

8. Demonstrates knowledge of ICD-9 coding / CPT / HCPCs to ensure Arnot Health to receive the maximum reimbursement that is allowable.

9. Demonstrates knowledge of Medicare requirements for approved ICD-9 codes and to communicate to the provider when a code is not approved, and knowledge of Medicare waivers.

10. Demonstrates the ability to accurately pre-authorize / pre-certify patients exams for all departments to ensure the smooth daily operation of the department..

11. Has knowledge of the method of proper sequencing of exams (ie. prioritization).

12. Communicates all questions to the appropriate department.

13. Has ability to conference with other departments to bring about conflict resolution to pre-authorization problems.

14. Demonstrates the ability to be cross-trained to other responsibilities of the department as required by the Supervisor/Director.

COMPUTER:

15. Demonstrates basic computer skills.

16. Demonstrates the knowledge and ability to work within the Arnot Health's computer system.

17. Maintains computer security.

WORKING RELATIONSHIP:

18. Has general knowledge of the Hospital's departments and how these departments interact with each other.

19. Interacts with physician and physician's offices in a positive and courteous manner.

20. Establishes and maintains collaborative working relationships with other health team members.

21. May perform other duties as requested by supervisor/manager which contributes to the smooth operation of the department.

QUALITY:

22. Demonstrates reliability in the conscientious, complete and accurate manner in which work assignments are performed.

23. Demonstrates Quality Improvement principles in daily work and participates in QI monitoring and reporting.

QUANTITY:

24. Demonstrates flexibility in work schedule to meet the needs of the department.

25. Demonstrates the ability to perform multiple tasks as required by the position.

26. Continuously utilizes time to maximize full potential, sets priorities and is uses good organizational skills.

SAFETY:

27. Functions within an awareness of risk management and safety issues, reports concerns appropriately.

28. Maintains complete understanding of the Arnot Health's emergency codes.

PROFESSIONALISM:

29. Is accountable for own actions.

30. Maintains professional behavior and appearance. Wears Arnot Health's ID Badge.

31. Maintains and respects patients and patient confidentiality.

32. Addresses internal and external customers in a pleasant and respectful manner, displaying courtesy at all times.

33. Attends staff meetings.

OTHER:

34. Is responsible for attending all annual mandatory educational programs as required by position.

35. Employee understands and demonstrates the importance of satisfying the needs of the customer/patient by interacting with him/her in a friendly and caring way, being attentive to the customer's needs, both psychologically and physically, and by taking the initiative to maintain communication with the customer in order to provide a secure and pleasant experience with Arnot Health.

36. It is understood that this job description lists typical duties for the classification and is not to be considered inclusive of all duties that may be assigned

EDUCATION:

Mandatory: Clinical experience in various areas is needed/and or coding in various areas. ICD9/CPT coding certifications or prior billing experience.

High School graduate or equivalent. Hospital experience preferred.

EXPERIENCE:

1. Good organizational, communication, and customer relations skills.

2. Telephone courtesy.

3. Service oriented experience preferred.

CARDIOPULMONARY RESUSCITATION (CPR) REQUIREMENTS:

No CPR required.

PHYSICAL DEMANDS:

Light physical effort. Typical office job.

EXPOSURE CATEGORY:

Category III. Tasks that involve no exposure to blood, body fluids, or tissues. Category I tasks are not a condition of employment.

** A.D.A. Essential Functions