Prior Authorization Representative

Position Details:

• Collection of demographic information using Meditech (Electronic Medical Record)
  • Collect basic personal information from patient including age, race, ethnicities
  • Collect addresses, phone numbers and other contact information
  • Collect next of kin information
  • Collect insurance/coverage information. Be able to discern what information is required based on type of insurance, i.e., on the job injury, motor vehicle accident, etc.
  • Sequence the insurance in the correct order according to guidelines
  • Based on specific criteria, request additional information, i.e. MSPQ/COB
• Verification of insurance coverage using AccuReg
  • Review feedback from AccuReg for any issues related to non-coverage or data accuracy
  • Review with the patient any feedback and reconcile accordingly
  • Ability to decipher the appropriate action based on AccuReg feedback, i.e., change the information in Meditech or enter a dispute so a more senior person can review
  • Verify insurance prior to the call
• Completion of Prior Authorization
  • Assessing patient medical records and documentation to determine the necessity of procedures and treatments.
  • Completing all the required fields and making accurate and complete notes to assist the HMC colleague who completes registration on site
  • Preparing and submitting prior authorization requests to insurance companies for approval.
  • Liaising with insurance companies to follow up on pending authorizations and resolve any issues or discrepancies.
  • Informing patients about the status of their authorization requests and explaining any delays or denials.
  • Keeping detailed records of all authorization requests, approvals, denials, and communications with insurance providers.
  • Ensuring all authorization processes comply with hospital policies, insurance guidelines, and regulatory requirements.
  • Working closely with healthcare providers, billing departments, and other hospital staff to ensure smooth and efficient authorization processes.
  • Addressing and resolving any issues that arise during the authorization process, including appeals for denied requests.
  • Generating reports on authorization activities, including approval rates, turnaround times, and any trends or issues identified.

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Qualifications: 

• Required
  • High school diploma or equivalent is required.
• Preferred           
  • Two to three years of working in healthcare office setting 
  • Accuracy and attention to detail. Proactive approach to problem-solving and process improvement.
  • Strong verbal and written communication skills, good organizational skills, efficient in computer operations including Microsoft Word, Excel, and Teams.
  • Professional and courteous demeanor, excellent office and phone etiquette.
  • Coding Certificate

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Patient Interaction: Continuous

HIPAA: This position will have access to the following Protected Health Information in order to perform the duties related to their position at Hays Medical Center based on the following criteria:

• Primary – required (routine) to do the job
  • Patient demographics
  • Insurance/Coverage information:
  • Scheduled service/provider
• Secondary   - occasionally necessary to perform the job
• None- no approved access
  • Clinical information beyond type of service
  • Coding

Description of Information
Primary:
Patient Demographic Information (information used to identify a person): Name, Date of Birth, Address, Race, Marital Status, Religion

Secondary:

Clinical Information (information that describes a patient’s health status): Diagnosis, Reports/Medical Notes, Test Results, Problem List, Procedures, History and Physical

Coding Information (clinical information that is in (alpha) numeric format): ICD-9 Codes, Rev Codes, CPT Codes

Financial Information/Insurance (information related to insurance, billing and payment): Billing Information, Payer Name, Payer ID, Account Balances, Plan Elements Covered, Payment Information, Payment Rates