What are the responsibilities and job description for the Prior Authorization Specialist position at Vista Healthcare?
Essential Functions/Responsibilities:
- Answer calls from patients and physician offices using exemplary customer service skills.
- Accurately enter required information, non-clinical and clinical, into computer database.
- Review clinical data matching it against specified medical criteria and follow established procedures for authorizing request for further review.
- Review incoming orders for completeness to determine if procedure ordered will be covered by insurance (in some cases, pre-certification is not warranted).
- Complete follow-up with physicians for orders still waiting for documentation.
- Contact physicians offices to obtain missing documentation to complete orders.
- Works with patients insurance companies to pre-certify/authorize procedures as ordered by the referring physician.
- Contact ordering physician with update if procedure is denied and assist with scheduling peer to peer reviews, if needed.
- Once order is complete, contact patient to confirm receipt of order and inform patient he/she will receive a scheduling call once insurance has been approved.
- Monitor pre-certification status to ensure timely processing and completion.
- Log order into the appropriate authorization spreadsheet and schedule procedure once approved.
- Maintain patient confidentiality as defined by state, federal and company regulations.
- Establish effective rapport with other employees, professional support service staff, customers, clients, patients, families, and physicians.
- Actively support departmental and corporate strategic plans and ensure successful implementation.
- Maintain cooperative working relationships with all clinics and providers.
Qualifications:
- Six months of previous experience in medical prior authorization. Will train the right person
- Knowledge of CPT and ICD-10 codes.
- Familiarity with medical terminology.
- High School Education or GED.
- Ability to interact with patients, insurers, and office team members in a responsible, professional, and ethical manner.
- Must be able to function effectively in a team-oriented environment.
- Must be able to work independently with limited direction.
- Must be reliable and demonstrate sound judgment and initiative.
- Able to work in a high volume/fast-paced environment.