JOB SUMMARY:

This position will facilitate the mission of Metro Community Health Center to ensure the delivery of quality patient care and coordination of supportive services within the health center. The individual will administer to the needs of the patients by following the scope of practice and standards of care accurately.

ESSENTIAL FUNCATIONS: 

• Demonstrate a high level of skill at building relationships and customer service
• Demonstrate interpersonal savvy and influence skills in managing difficult clients and patients
• Demonstrate high degree of knowledge and competency in the practice of medicine and associated charting requirements
• Demonstrate a high level of problem-solving skills to better serve patients and staff
• Strong attention to detail and accuracy
• Ability to utilize computers for data entry and information retrieval
• Excellent verbal and written communication skills.
• Continually improve work process to enhance service and customer relations
• Works to improve prior authorization processes, communication, and patient care as it relates to various insurance companies’ regulations.
• Demonstrated success and familiarity with tools, technology, and systems typically found within most progressive health care environments (i.e. personal computer skills, spreadsheets, word processing, patient records systems, EMR systems, etc.)
  • Experience with insurer’s authorization submission portals preferred
• Responsible for receiving, processing and documenting referral and prior authorization requests (medications, test/procedures, DMEs, etc.).
• Stay abreast of continual changes in the health insurance Managed Care arena and communicates those changes as appropriate.
• Assists the clerical and clinical teams with the coordination of patients
• Have an understanding of provider charting practices and how to find supporting documentation inside the patient chart
• Attend meetings, patient conferences, planning sessions, related to quality assurance, patient care, and other related topics within the health center
• Attend seminars and maintain all certifications requirements for continuing education and best practices
• Participate in quality strategies to evaluate compliance with standards and to identify opportunities to improve patient outcomes
• Assists the clinical team with quality assurance standards and measures
• Ability to utilize computers for data entry and information retrieval
• Excellent verbal and written communication skills in a professional manner
• Ability to implement, and evaluate operational and administrative processes
• Maintains HIPAA compliance practices at all times
• Ensures insurance carrier documentation requirements are met and referral support documentation is charted in patient's medical record.
• Efficiently manages correspondence with patients, physicians, specialists, and insurance companies. 
• Work in coordination with medical providers regarding issues in documentation, diagnoses, etc in regard to patient’s prior authorizations.
• Work in coordination with medical providers regarding denials to ensure quality patient outcomes.
• Documents pertinent information in the patient record regarding authorizations and communications with patients.
• Works in collaboration with the Financial Department to improve the Revenue Cycle
• Performs other duties as assigned

POSITION REQUIREMENTS: 

Education/Experience

• High school diploma or equivalent
• 3-5 years of prior experience performing authorizations and referrals
  • Some combination of education/certification may be accepted in lieu of experience.
  • Education Equivalent

Skills/Abilities

• Demonstrated experience of developing an effective rapport with the patients, staff members, insurance companies, etc. in an effort to provide comprehensive healthcare across the life span.
• Significant knowledge of medical practices and insurance within a primary care environment 
• Knowledge of relevant prior authorization portals
• Knowledge of formularies and other insurance related procedures regarding prior authorizations
• Communication Skills
• Knowledge and understanding of EMR software. Athena One experience preferred.
• Medical Terminology
  • CPT
  • ICD-10
• Customer Service
• Computers/Microsoft Office Suite (Excel, Word, Etc)
• Medical Insurance Knowledge
  • Medicare/Medicaid
  • Private Payers