What are the responsibilities and job description for the Prior Authorization/Referral Specialist position at Froedtert South, Inc.?
Position Purpose:
A Pre-Authorization/Referral Specialist is responsible for determining insurance eligibility/benefits and ensuring pre-certification (authorization/referral) requirements are met for both the facility and professional services. The Pre-Authorization/Referral Specialist provides detailed documentation and communication with both payors and clinicians to obtain prior-authorizations. Obtains clinical information to support medical necessity.
Knowledge, Skills & Abilities required:
- Experience in pre-authorization/referrals, patient registration, insurance verification and health insurance plans
- Knowledge of online insurance pre-authorization process and working with various payors
- Excellent computer and customer service skills
- Familiarity with Medical Terminology
- Demonstrated ability to efficiently organize work, while maintaining a high level of accuracy and productivity
- Knowledge of ICD-10, CPT and HCPC codes and use
- Familiarity with internet, email and Microsoft Office
- Effective written and verbal communication skills required
Principal Accountabilities and Essential Duties of the Job:
- Verifies insurance eligibility and benefit levels to ensure adequate coverage for identified services
- Obtains pre-certification, authorization and referral approval for required services for both the facility and professional services.
- Calculates “billable units” for medication as identified by the payer rather than utilizing patient visits.
- Coordinates and supplies information to the review organization (payer) including clinical information and/or letter of medical necessity for determination of benefits. Coordinates peer-to-peer review, when required.
- Communicates with patients, clinicians, financial counselors and others as necessary to facilitate authorization process.
- Completes accurate documentation in the healthcare software
- Completes inpatient notification to all payers using their preferred method within 24 hours of admission
- Ensures timely and accurate insurance authorizations/referrals are in place prior to services being rendered
- Notifies patient/department when authorization/referral has not been obtained prior to service date
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