Description

JOB TITLE: Pre-Authorization Specialist

**4 DAY WORK WEEK

**COMPETITIVE BENEFITS PACKAGE

**FREE PARKING

GENERAL STATEMENT OF DUTIES: Responsible for assisting with the day-to-day functions of the Prior-Auth department. The goal is to improve efficiency and decrease turn-around time related to prescription medications and procedures requiring prior- authorization from any payer source. Assists in the delivery of health care and patient care management.

SUPERVISION RECEIVED: Manager of Call Center/ Director of Clinical Practice

Location: Hybrid / Some in office days Wheaton

Cell Phone Required

SUPERVISION EXERCISED: None

TYPICAL WORKING CONDITIONS:

Exposure to bio-hazardous materials, medicinal preparations. Fast paced, busy medical office.

EXAMPLES OF DUTIES: (List may not include all the duties assigned.)

1. Completes prior- authorization requests for medication and procedures.
2. Assures timely completion of all prior authorization requests with a goal of no longer than 72 hours turn-around time.
3. Assists with medical necessity documentation to expedite approvals of medications and procedures.
4. Collaborates with providers/MAs/payers/pharmacist/patients to assure appropriateness of medications/ procedures needing prior authorization and to reduce barriers to patient receiving quality patient care.
5. Assists with developing and implementing prior authorization workflows, policies, and procedures.
6. Partners and collaborates with other departments cross functionally regarding prior- authorization and/or clinical care services.
7. Build effective and professional relationships with internal providers, MAs and external community.
8. Checks patient charts to make sure that Physicians’ notes, lab work, x-ray reports, outside tests and x-ray reports, and other Physicians’ reports are in the electronic chart when working on pre-authorizations.
9. Screens patient telephone calls to access need of prior authorizations.
10. Provides patients with educational information after Physician approval.
11. Knows the different types of insurance that the office participates with in order to prepare obtain prior authorizations for medications patients need.
12. Remains current with the policies mandated by Federal and local governments, Medicare/Medicaid programs and other private healthcare programs regarding handling of medication prior authorization requirements.
13. Performs related work as required.
14. Other Duties as Assigned: The assignment of duties to employees is not limited to the content of this job description. Other tasks and assignments may be related to the work usually assigned to the employee, but in some circumstances may be completely unrelated.

PERFORMANCE REQUIREMENTS: (Knowledge, Skills, and Abilities)

1. Demonstrates a comprehensive knowledge of pharmacology.
2. Demonstrates strong knowledge of medical necessity criteria related to medications and procedures and the required supporting documentation to maximize approval.
3. Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, pharmacies, insurance companies, patients, and families.
4. Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment.
5. Demonstrates effective communication methods to assist in training and to relate effectively to upper management.
6. Ability to communicate clearly both orally and in writing.
7. Ability to examine documents for accuracy and completeness.
8. Knowledge of medical practices to assist in giving patient care.
9. Knowledge of examination and diagnostic procedures.
10. Knowledge of medical equipment and instruments.
11. Knowledge of common safety hazards and precautions to establish a safe work environment.
12. Knowledge of different insurance company requirements with regard to medications and procedures pre-authorizations requirements, laboratory handling and billing, including appropriate co-payments.
13. Skill in maintaining clear notes in patients’ charts.
14. Skill in establishing and maintaining effective working relationships with patients, other staff, and the public.
15. Skill in using calculator.
16. Skill in using computer
17. Ability to react calmly and effectively in emergency situations.
18. Ability to adapt to changes in the department.
19. Ability to identify problems.
20. Skill in training new pre-auth team members in office operation and procedures.

COMPLIANCE:

1. Follows guidelines for maintaining patient confidentiality
2. Follows compliance requirements mandated by OSHA.
3. Follows compliance requirements pertaining to collection and handling of laboratory specimens including, but not exclusive of, collection, temperature, containers and proper disposal of biohazard materials.
4. Demonstrates a strong commitment to honest and responsible corporate conduct.
5. Identifies, reports and/or prevents any fraudulent or unethical behavior.
6. Initiates notification to management if inappropriate behavior is observed within the organization.

HIPAA-Minimum Necessary Access to PHI

The responsibilities associated with this position allow access to the computer “role” of ARA Check In/Out only.

We are committed to enforcing minimum necessary access to our patients’ PHI by limiting the uses and disclosures of this information within our practice. In order for this employee to carry out his/her job (carry out TPO) in a manner that best serves our patients, the employee needs access the afore mentioned computer “role”. Role descriptions are explicitly defined in our HIPAA manual. Access to computer information is password protected. Upon termination of an employee, his/her password will be deleted from the system.

EDUCATION:

CMA or RN Degree

EXPERIENCE:

Two years’ experience in a medical office/ or pharmacy tech

Proficient PC skills including EHR and Excel software.

DISCLAIMER:

The foregoing description is not intended, and should not be construed, to be an exhaustive list of all responsibilities, skills, efforts, or working conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Qualifications