Prior Authorization Specialist

At ELM Management Services, the Prior Authorization Specialist plays a crucial role in ensuring that patients receive the necessary approvals and benefits before their scheduled outpatient services. This position involves close collaboration with physicians and staff to navigate the process of obtaining prior authorization. By securing these authorizations in advance, the specialist helps streamline the patient’s experience and ensures that they can receive the care they need without delays. Reporting directly to the ASC Administrator, this role holds significant responsibility in managing the administrative aspects of outpatient care and facilitating smooth interactions between healthcare providers, patients, and insurance providers.

Essential Functions:

• Maintains responsibility for all outpatient authorization processes
• Confirms insurance verification, insurance eligibility, benefits, and network status for all services
• Ensures accurate ICD, CPT codes and related medical records are submitted in the authorization request
• Follows up on delayed or denied authorization requests and escalates for resolution
• Acts as a liaison between the payer and clinic schedulers/medical support staff
• Maintains confidentiality of patient information, in accordance with company policy and HIPPA regulations
• Creates referrals accurately
• Creates detailed documentation and maintains/stores the authorization paper/electronic trail
• May work to resolve claims denials related to the prior authorization
• Demonstrates ability to tactfully handle difficult situations
• Documents thorough explanatory notes on patient accounts, concerning any non-routine circumstances, clarifying special billing processes
• Understands the outpatient scheduling process, front-end to back-end
• Assists physicians and office staff to expedite scheduling
• Answers incoming phone calls and follows through with requests made by patients and staff personnel
• Attempts to collect the estimated self-pay balance of all outpatient services/accounts, at the earliest possible collection control point
• Identifies those patients without adequate insurance coverage and makes contact with the patient or guarantor to determine guarantors’ ability to pay non-covered charges, if applicable
• Contacts scheduled patients to obtain pre-service information, explain financial policies, estimates, balances, and obtain a promise to pay on or before services are rendered
• Documents concise and understandable notes regarding all accounts collection activity, as well as each patient or guarantor interaction
  
  
  

Other Duties and Responsibilities:

• Maintains quality and safety in accordance with company policy and HIPPA regulations.
• Observes work hours and provides proper notice of absences, tardiness, or work schedule changes
• Maintains courteous and cooperative working relationships with management, patients, physicians, other professional contacts, and the public
• Presents a well-groomed and professional image
• Maintains a working knowledge of available information system capabilities and performs all system applications that are required
• Consistently demonstrates the ability to organize work, recognizes and establishes appropriate work priorities, and completes work in a productive manner, without creating backlog
• Demonstrates a high-level of customer service skills
• Maintains proficiency in data entry skills
• Demonstrates ability to tactfully handle difficult situations and/or conversations
• Provides feedback to management concerning integrity issues
• Perform other work-related duties as requested/directed by management
• Completes annual mandatory training as required
  
  
  

Knowledge, Skills, and Abilities:

• Ability to use discretion and work independently under general supervision
• Ability to understand and adhere to the Professional Code of Conduct
  
  
  

Qualifications & Requirements:

• Minimum of one year healthcare experience
• Must meet pre-employment requirements and maintain all applicable state and job-related guidelines for background screening. Depending on state-specific requirements, this may include drug testing, health screening, CPR/Basic First Aid, and license/credential verifications
  
  
  

Reasonable accommodation may be made to enable individuals with disabilities to perform these essential functions.

Physical Requirements & Working Conditions:

These physical demands are representative of the physical requirements necessary for an employee to successfully perform the essential functions of the job. Reasonable accommodation can be made to enable people with disabilities; these are made on a case-by-case basis.

While performing the responsibilities of the role, the employee is required to talk and hear. The employee is often required to sit and use his or her hands and fingers. The employee is occasionally required to stand, walk, reach with arms and hands, climb or balance, and to stoop, kneel, crouch or crawl. Vision abilities required by this job include close vision.

Limitations and Disclaimer:

The above job description is meant to describe the general nature and level of work being performed; it is not intended to be construed as an exhaustive list of all responsibilities, duties and skills required for the position. Other duties may be assigned from time to time.

Equal Employment Opportunity Statement:

ELM is an equal opportunity employer committed to diversity and inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sex, sexual orientation, transgender status, gender dysphoria, national origin, age, religion, disability, military, and veteran status, marital or parental status, citizenship status, genetic information or any other factor which cannot lawfully be used as a basis for an employment decision.