Prior Authorization Specialist

Job Preview

The Prior Authorization Specialist is responsible for ensuring that payers are prepared to reimburse Hopedale Medical Complex for scheduled services in accordance with the payer-provider contract. The representative will contact payers to request service authorizations and may collect financial and/or demographic information from patients as needed. The Prior Authorization Specialist is also responsible for determining insurance coverage for tests/procedures and counseling patients regarding this coverage, as well as performing financial counseling duties.

Responsibilities

Prior Authorizations:

• Verifies patient’s insurance and benefits information.
• Obtains prior authorizations from third-party payers in accordance with payer requirements.
• Works with other departments to gather the clinical information required by the payer to authorize services.
• Maintains accurate records of authorizations within the EMR.
• Works with the business office to support appeal efforts for authorization related denials.
• Complies with HIPAA regulations, as well as the organization's policies and procedures regarding patient privacy and confidentiality.
• Maintains professional tone at all times when communicating with patients and payer representatives.

Other Duties:

• Completes approved adjustments as requested and adds charges as requested.
• Keep filing updated for easy access.
• Keep the waiting area orderly throughout the day.
• Assist in maintaining accurate patient business records.
• Orders and maintains supplies as required.
• Maintains good working relationship both within the department and with other departments.
• Demonstrates an ability to be flexible, organized and function well in a stressful situation.
• Treat patients and their families with respect and dignity; ensures confidentiality of patients personal and medical information.
• Follows established departmental policies, procedures, and objectives. Continues quality improvement objectives and safety, environmental and/or infection control standards.
• Other duties as assigned by the Patient Access Manager.

Job Requirements:

• Minimum of high school diploma. Some college or BA preferred.
• Knowledge of medical terminology and experience in medical office reception.
• Knowledge of patient registration procedures and documentation.
• Ability to prepare administrative paperwork and spreadsheets as requested.
• Ability to interact and communicate with people over the telephone, often in stressful situations.
• Above average ability to analyze and solve problems.
• Skill in the use of personal computers and Microsoft Office Suite (Word, Excel, Outlook).
• Excellent verbal and written communication skills required.
• Expert knowledge of insurance procedures and documentation of third-party medical insurance payers.
• Ability to work independently with little general supervision.
• Excellent telephone techniques and rapport. Experience with a multi-line phone system.
• Ability to perform the essential functions and requirements of the job.

Physical Demands

• Department is normal office environment.
• Ability to lift and move objects up to 25lbs.
• At times high patient traffic and stressful situations.
• In addition to the above requirements, some duties vary from sedentary to light exertion. Some of the duties will require the ability to get between buildings throughout Hopedale Medical Complex.
• Productivity and accuracy are monitored by the Patient Access Manager.