Prior Authorization Specialist

Location: 8435 Stemmons Bldg.

Summary

Responsible for performing benefits verification and prior authorization functions with insurance carriers to ensure optimal reimbursement for high cost medications, surgeries and procedures, within an established time frame, for patient cases submitted to Patient Financial Services.

Responsibilities

• Ensures correct referral form is completed for patient's plan. Reviews referral for accurate information prior to authorization to include patient provider identification information, clinic or procedure requested, and appropriate CPT-4 /billing codes. Contacts clinic to obtain additional information as needed.
• Assists with medical necessity documentation and clearance to expedite approvals and ensure that appropriate follow-up is performed.
• Collaborates with other departments, clinics, and procedures areas to assist in obtaining authorization/pre-certifications in a cross functional manner.
• Contacts plans to extend authorization dates, obtain additional visits and urgent/priority authorizations/pre-certifications, as needed.
• Notifies clinic/procedure area, Nurse Navigator, Providers and/or patients to inform them of the authorization denials. Obtains additional clinical information for denials and submits appeals to the plan for further consideration.
• Completes documentation of referrals in software to include the authorization number, number of visits, and the authorization period (dates) to ensure claims are paid in a timely manner.
• Utilizes software to process and track referrals and submit medical records to insurance carriers to expedite prior authorization processes.
• Creates patients' records and accounts and ensure that pre-authorization information is properly updated.
• Secures patients' demographics and medical information and ensures that all procedures are in sync with HIPPA compliance and regulation.
• Other duties as assigned.
  
  

Career Type: Support

• Individual contributors who support operational, functional or business strategy through tactical support of daily activities (clerical, administrative, technical). The majority of time is spent in the delivery of front line services or activities, typically under direct supervision.
• Works to deliver day-to-day objectives with impact typically limited to particular job area and/or department
• Makes minor adjustments to work methods to solve problems that are often routine and typically exist in current work processes and systems. Changes often require higher-level approval
• Requires knowledge of operational, functional, and/or business systems and practices
  
  

Competencies

• Leadership & Talent Management
• May provide guidance, helping to train and review work of entry level employees
• Organizational Impact Delivers on day-to-day objectives with direct impact on team/unit results with some supervision
• Daily challenges are typically of a routine nature, but may at times require interpretation or deviation from standard procedures
• Communication & Influence
• Communicates information that requires explanation or interpretation of moderate importance to the team/unit
  
  

Knowledge & Experience

• Requires broad knowledge of operational, functional, and/or business systems and practices typically obtained through some experience, education, or vocational training
  
  

Degree

• No advanced education is typically required
  
  

Years of Experience

• Between 3 and 6
  
  

Requirements

Education Requirements

• HS/GED High School Diploma or GED.
  
  

Preferred

• None
  
  

Required Certifications / Licensure

• None
  
  

Preferred Certifications / Licensure

• None
  
  

Equivalent Education and/or Experience

• None
  
  

Requisition ID: 986121