Prior Authorization Specialist

Essential Duties and Responsibilities:

• Review chart documentation to ensure patient meets medical policy guidelines to support the order/procedure.
• Prioritize incoming authorization requests according to urgency
• Performs initial insurance benefit verification through payer website or AccuReg system
• Obtain procedural authorization via payer website or by phone and follow up regularly on all pending cases
• Communicate with clinical areas on information needed and updates as to approval or denial of authorization
• Maintain individual payer files to include up to date requirements needed to successfully obtain authorizations
• Initiate appeals for denied authorizations
• Respond to clinic questions regarding payer medical policy guidelines
• Confirm accuracy of CPT and ICD-10 diagnoses in the procedure order 
• Contact patients to discuss authorization status if needed
• Answers department telephones appropriately and handles routine questions involving prior authorization issues
• Demonstrates ability to use EMR system to locate and upload medical record information
• Make necessary arrangements for medical records requests, completion of additional information requests, etc. as requested by insurance companies.
• Customer service skills for interacting with patients regarding authorizations including communicating with patients and family members of diverse ages and backgrounds
• Consistently reports to work at the scheduled time in a punctual manner and at the assigned job location.
• Regularly attend monthly staff meetings and continuing educational sessions as requested.
• Attends all required Safety Training programs and can describe his/her responsibilities related to general safety, department/service safety and specific job-related hazards.
• Follows the Hospital Exposure Control Plans/Bloodborne and Airborne Pathogens.
• Demonstrates respect and regard for the dignity of all patients, families, visitors and fellow employees to ensure a professional, responsible and courteous environment.
• Promotes effective working relations and works effectively as part of a department/unit team inter- and intra- departmentally to facilitate the department’s/unit’s ability to meet its goals and objectives.

Non-Essential Duties and Responsibilities:

• Perform other duties as assigned

Professional Requirements

• Knowledge of procedure authorization and its direct impact on the practice’s revenue cycle
• Understanding of payer medical policy guidelines while utilizing these guidelines to manage authorizations effectively
• Basic understanding of human anatomy, specifically musculoskeletal
• Proficient use of CPT and ICD-10 codes
• Excellent computer skills including Excel, Word, and Internet use
• Detail oriented with above average organizational skills
• Plans and prioritizes to meet deadlines
• Excellent customer service skills; communicates clearly and effectively
• Ability to multitask and remain focused while managing a high-volume, time-sensitive workload
• Complete annual education requirements.
• Maintain patient confidentiality at all times.
• Report to work on time and as scheduled.
• Wear identification while on duty.
• Maintain regulatory requirements, including all state, federal and local regulations.
• Represent the organization in a positive and professional manner at all times.
• Comply with all organizational policies.
• Conduct oneself as a professional in accordance with PRIDE values.
• Participate in performance improvement and continuous quality improvement activities.
• Attend regular staff meetings and in-services.

Job Requirements:

• High School Diploma required.
• One to two years prior hospital/medical office experience required.
• One to two years medical prior authorization preferred.
• Prior knowledge of medical terminology preferred.
• Previous insurance experience preferred.

Organizational/Core Competencies:

• Quality Service
• Team Work
• Communication
• Respect for Others
• Time and Priority Management