Prior Authorization Specialist

Job Summary: The prior authorization specialist is responsible for prior authorization operations within the primary care clinics, establishing and standardizing systems and procedures for the distribution and use of health information throughout the organization, coordinating prior authorization functions with all other departments.

Job Duties: 

• Obtain prior authorizations for imaging and procedures from appropriate payors.
• Maintain ongoing tracking and appropriate documentation on prior authorizations to promote team awareness and ensure patient safety
• Ensure complete and accurate registration, including patient demographic and current insurance information
• Assemble information concerning patient's clinical background and referral needs. Per referral guidelines, provide appropriate clinical information to specialist- 
• Contact review organizations and insurance companies to ensure prior approval requirements are met. Present necessary medical information such as history, diagnosis and prognosis. Provide specific medical information to financial services to maximize reimbursement to the hospital and physicians
• Review details and expectations about the prior authorization with patients as needed
• Ensure that prior authorizations are addressed in a timely manner
• Identify and utilize cultural and community resources. Establish and maintain relationships with identified service providers
• Abide by HIPPA and Hospital policies & procedures
• Assists with Referrals as needed
• Performs other duties as assigned

Job Requirements:    
•    Strong customer service focus
•    Strong verbal and written communication skills
•    Able to work as part of a team and independently
•    Strong organizational and time management skills
•    Able to prioritize effectively including medical triage prioritization
•    Good judgement, resourcefulness, and problem solving abilities
•    Able to take initiative and follow through with delegated tasks
•    Able to act with integrity, professionalism, and confidentiality 
•    Strong attention to detail
•    Strong proficiency in medical terminology & abbreviations

Preferred Skills:    
•    Knowledge of prior authorizations process for different services (radiology,  pharmacology & laboratory services) and insurance providers (commercial, Medicare & Medicaid),  solid understanding and knowledge of payer contractual requirements, experience with insurance verification, experience and familiarity with using insurance portals
•    Previous clinical support experience in a healthcare setting with  basic knowledge of CPT & ICD 10 codes,  working knowledge of anatomy, physiology & the disease process to effectively communicate medical necessity criteria for procedures ordered or to effectively appeal an adverse determination