Prior Authorization Specialist

Job Description

Job Description

Job Description

General Summary / Overview Statement

The Prior Authorization Specialist (PAS) is an essential role responsible for facilitating exceptional patient experience, by securing authorizations for all scheduled services related to medical and surgical admissions across entities,.

Principal Duties and Responsibilities

Maintains expert-level knowledge about industry; utilizes to manage pay models of complicated patient care plans and facilitates exceptional patient experiences as aligned with organizational values and mission.

Acts as subject matter expert and guide to broad employee base, particularly providers, to educate and communicate on requirements, processes and adjustments needed throughout the patient care journey.

Interacts directly with EPIC Auth / Cert, Registration and Referral Shell, entering data accurately to coordinate all elements required for payment of services rendered, which includes, but is not limited to, appropriate CPT Procedure and Diagnosis codes, rendering Physician(s), level of care, and facility, i.e.

Consults with all levels of Hospital professionals, administrative and support staff, as well as patients, and representatives of other organizations where advanced expertise in communications is necessary to lead with tact, inclusivity, patience, and respect, while maintaining confidentiality and achieving consensus with the lens of exceptional patient experience.

Interacts directly in EPIC Clinical System to extract necessary supporting clinical data to submit to Medical Insurance to secure authorization, e.g., clinical office notes, radiology reports, lab test and results, PT / OT notes, imaging results and photos.  Each type of surgery, as well as each insurance company has different needs for information required to authorize the surgery, and review and understanding of all is needed to get an approval for services.

Contacts insurance companies, managed care plans, outside agencies, and intermediaries to verify insurance coverage and benefits.  Determines if any pre-admission / pre-visit requirements exist, e.g., predetermination of medical necessity, need for out of network plan auth required in addition to the service / procedural auth, etc.

Determines eligibility for admission / treatment in compliance with hospital policy, utilization review criteria, and State and Federal regulations and / or guidelines.  Need to understand which payers are contracted, need to determine what level and type of care, etc.

Updates, obtains and / or verifies all pertinent data necessary to complete required registration, admission, demographic, and financial information ensuring both timely access and accurate billing.  Data is entered via many sources and need to determine that all sources of information are accurate and update as needed.

Ability to identify incomplete clinical documentation that is needed to obtain approval for services.  Interacts directly with physicians / clinicians / physicians ’ office staff via EPIC, phone calls and Outlook to identify what is missing and to collect further complete and appropriate patient data and clinical information necessary to submit to Medical Insurance to review for authorization of services scheduled.

Compiles, uploads, and submits all the above clinical information from Epic required to obtain preadmission approvals and precertification via the Medical Insurance Payer Portals.

Determines when problematic preadmissions must be referred to the Sr. Manager and / or Director, e.g., legal issues, complex financial issues, and patients with special insurance policy exclusions.

Acts as liaison between physicians, insurance company, Patient Financial Services across multiple campuses.

Monitors pending cases to ensure that approvals are obtained prior to admission or visit. Informs doctor’s office of any additional clinical requested, including notes that are lacking tried and true therapies / refrainment, e.g., Orthopedic or Neuro Spine cases.

Advises uninsured and underinsured patients regarding available programs.  Makes appropriate referrals to Patient Financial Services Department in a timely manner so that coverage may be secured ASAP and the accompanying authorization, if any, is submitted as soon as Payer source is identified.

Advises and refers to Patient Financial Services when it appears a patient liability estimate is in order. Works closely with PFS, Practice staff and the patient or his / her family to aid in an understanding of liability and informs of the expectations of Brigham Health regarding collection of liability.

Reviews and follows-up on all emergency and unscreened admissions as soon as possible, within 24 business hours of admission at the latest, to identify and minimize financial risk to the institution.

Follows all cases throughout the duration of the admission, working with Utilization Review (UR) Department every few days in Ontrac to send concurrent review clinicals. Must connect with Payer continually throughout the admission for updated authorization days, alerting UR to any medical necessity denials so they can conduct in-house Peer to Peer Review.

Reviews RTE eligibility system in EPIC throughout admission for any Payer changes or discrepancies and follow up for new prior authorization when Payer changes mid-admission.

Reviews cases daily for patient class changes, e.g., coverts from outpatient to inpatient, to modify or request authorization updates.

Reviews Ontrac list daily for exceptions which include some of the above, but in addition : expected date changes in surgery, primary and secondary payer changes, high risk high dollar accounts, and other important notifications.

Scans authorization related information into Epic Media Manager and documents notes in accordance with QA Metrics. Works closely with Authorization Denials Team to avert write offs by researching cases and providing back-up documentation for possible prior auth appeals.

Stays current with Payer changes in authorization requirements and restrictions, e.g., additional CPT procedure codes now requiring authorizations, or additional tried therapies, etc.

Qualifications

Bachelor’s degree or equivalent preferred; high school diploma required.

Proven experience in like setting is acceptable in lieu of educational requirements.

2 years’ experience in hospital setting such as Patient Access, Doctor’s Office, Inpatient Unit, Patient Accounts Billing or at a related type of medical institution or medical payer, e.g., BCBS, Tufts, etc.… is preferred

Knowledge of insurances and / or managed care authorization requirements a plus

Knowledge of medical terminology and / or coding is preferred

Familiarity with a hospital legacy system, Microsoft Office, and SharePoint preferred

Bilingual is helpful

Experience with, knowledge of, or desire to learn about elements of exceptional patient experience environments, as related to the function.

Education : High School

Company Description

Compunnel Software Group, Inc., the parent organization of Compunnel Healthcare has expanded its staffing services within the blooming healthcare industry. Born from company’s 35 years of experience in Compunnel Healthcare provides customized, cost-effective solutions to your healthcare organization’s multiple staffing needs.

Company Description

Compunnel Software Group, Inc., the parent organization of Compunnel Healthcare has expanded its staffing services within the blooming healthcare industry. Born from company’s 35 years of experience in Compunnel Healthcare provides customized, cost-effective solutions to your healthcare organization’s multiple staffing needs.