What are the responsibilities and job description for the Prior Authorization Specialist position at Central Outreach Wellness Center Llc?
Job Description
The Prior Authorization Specialist works under the guidance of the Prior Authorization Clinic Manager and is responsible for a critical aspect of patient care by performing all clerical duties required to obtain insurance prior authorizations for medications administered in the office.
This role is essential to ensuring that patients receive their prescribed treatments without unnecessary delays. The Specialist will create, maintain, and manage essential resources, including access to various insurance portals, to streamline the authorization process.
Accurate and consistent documentation must be recorded in EPIC to validate each obtained insurance authorization. Additionally, the Specialist will communicate any changes in payer requirements or federal regulations to their manager, healthcare providers, and other relevant clinical departments to ensure compliance and optimal patient care.
Key Responsibilities:
Daily Monitoring: Review the prior authorization work queue each day to verify the accuracy of patient insurance information. This includes scrutinizing eligibility and benefits to interpret and assess insurance pre-authorization requirements for all scheduled procedures, surgeries, and medications.
Insurance Communication: Establish contact with insurance companies to obtain prior authorization either through direct telephone calls or via online portals. The Specialist must ensure that all necessary clinical documentation is accurately provided to facilitate the authorization process before the scheduled date of injections or procedures.
Documentation in EPIC: Record essential prior authorization information in the EPIC system, which includes detailing the number of treatments authorized, the duration of the authorization, authorization numbers, and relevant contact or reference numbers from conversations with insurance providers.
Denial Management: Immediately notify the healthcare provider in instances where an insurance company denies a procedure, medication, or surgery. The Specialist will also assist in setting up peer-to-peer reviews to advocate for the patient’s needs effectively.
Collaboration with Pharmacy: Work closely with pharmacy staff to assess the list of preferred drugs covered under specific insurance plans. This includes notifying providers about any alternatives available when a prescribed medication is not covered.
Log Maintenance: Maintain a detailed log of any missed prior authorizations to track and follow up on them efficiently. Assist the manager in executing timely retro authorizations or appeal processes to recover revenue for the clinic.
Interdepartmental Collaboration: Collaborate with various internal departments on matters related to billing, information management, policies, and procedures, ensuring a comprehensive understanding and coordination of general operations regarding prior authorizations.
Additional Support When time permits, the Specialist may assist with general office responsibilities, such as managing incoming faxes and baskets, transcribing medical orders, and processing patient referrals.
Referral Monitoring: Monitor the referral work queue, ensuring timely processing, and perform additional duties as assigned to support overall departmental efficiency as needed.
Qualifications:
Educational Background: A high school diploma is preferred. Additional education in healthcare administration or a related field is a plus.
Experience: A minimum of one year of experience working with insurance processes, specifically in prior authorizations, is preferred. Familiarity with the healthcare system and various insurance plans is essential.
Knowledge and Skills: Proficient understanding of insurance terminology, procedures, and prior authorization processes is crucial for success in this role. Must exhibit superior communication skills and the ability to engage effectively and professionally with physicians, administrative and clinical staff, managers, patients, and insurance representatives.
Work Ethic: The ideal candidate must be highly self-motivated, possessing the ability to work independently while being an effective team player. Demonstrated organizational skills and excellent attention to detail are essential for managing multiple tasks.
Customer Service: Strong customer service skills are required, including the ability to handle inquiries and concerns from patients and ensure a positive experience throughout the authorization process. Proficiency in using computer systems, particularly EPIC and other relevant software, is also necessary.
