PFS Prior Authorization Specialist789-05

Title: PFS Prior Authorization Specialist

Reporting Relationship: Patient Financial Services Manager

Position Summary

To verify insurance coverage, pre-certification and/or pre-authorization requirements for Inpatient, Outpatient Observation and Surgery patients. To coordinate activities with the Utilization Review, Surgery and other departments to assure pre-certification requirements are met. All communications are conducted in a manner that will result in positive patient relations.

Certification

Essential Job Functions:

1. Coordinates activities with hospital departments to assist in meeting pre-certification or pre-authorization requirements for inpatients, 23 hour observation and surgery patients.

2. Communicates with the Outpatient Surgery and the Multi-Specialty Clinic departments to access schedules and assist in meeting insurance pre-certification requirements for patients on the surgery schedule.

3. Coordinate activities with Utilization Review staff to verify insurance eligibility and coordinate activities related to pre-certification requirements of Inpatients and 23-hour observation patients.

4. Contacts patient’s insurance company to verify coverage & benefits for inpatients, observation patients and surgery patients.

5. Contact the patient or his/her representative by phone to gather demographic and insurance information prior to the surgery date.

6. Contact insurance companies via internet and/or phone to verify insurance eligibility and document coverage and benefits.

7. Access the Medicare Common Working File to verify Medicare coverage, eligibility dates and other insurance coverage.

8. Enters patient demographic and insurance information in the Meditech EMR system efficiently and accurately.

9. Document information relating to insurance eligibility, pre-certification and/or pre-authorization information or confirmation numbers.

10. Follows up on insurance non-payment claims relating to pre-cert or pre-authorization requirements.

11. Handles phone, mail and personal inquiries from and regarding patient accounts.

12. Assists each person promptly, efficiently and courteously.

13. Follow through on all issues identified as requiring action as a result of inquiry.

14. Document all phone and personal inquiries in the Meditech EMR system.

15. Performs duties with a minimum of supervision, exhibits innovation and good judgment.

Other Job Functions:

1. Provides back-up for the PBX during vacancies and absences.

2. Enhances professional development by taking steps to remain knowledgeable of industry standards, and attending meetings and seminars as assigned. Actively participates in BBGH Performance Improvement activities.

3. Attends a minimum of 80% of mandatory staff meetings.

4. Contributes to the prevention of infectious disease among employees and patients by adhering to infection control policies and procedures.

5. Contributes to adequate staffing of department by reporting to work at scheduled time.

6. Contributes to effective guest relations by assisting patients, visitors and physicians to resolve expressed concerns and demonstrating a welcoming and helpful attitude.

7. Conserves hospital resources by using equipment and supplies as needed to perform job duties.

8. Keeps information confidential by adhering to the terms of personnel policy concerning confidentiality.

9. Maintains a clean and calm environment.

10. Completes all required paperwork/computer entry for each patient needed.

11. Follow the Standards of Behavior.

12. Utilize TeamSTEPPS tools.

13. Participate in Patient Experience.

14. Regular attendance

15. Performs other related duties as assigned or requested.

Job Qualifications:

Age Requirement

Required: Must be 19 years or older

Education

Required: High School Diploma or GED equivalent

Experience/Qualifications

Required: Computer Skills/Keyboarding

Preferred: Previous experience in use of telephone to gather customer information.

Licenses/Certifications

Required:

Preferred: Certified Patient Account Technician (CPAT)

Box Butte General Hospital is an Equal Opportunity Employer.

Post-offer/pre-employment background check and drug screen are required.