Job Summary

• Analyzes the prior authorization denials report to identify reason for denials in detail including inaccurate and/or missing information in detail.
• Works closely with management to evaluate payer changes or other items that may impact reimbursement affected by prior authorization.
• Recognizes billing errors and when to submit a reconsideration request for payment with all appropriate documentation.
• Analyzes denial reports and recommend changes to workflow as appropriate with impacted departments on any deficiencies in workflow or system build.
• Reviews denials report for patterns related to repeated denials from a particular insurance carrier. Understands how to identify errors and works with contract staff to address.
• Ensure patients receive the services that require prior authorization from insurance carriers by addressing and rectifying rejected claims that require additional documentation and/or Peer to Peer Consultation.
• Collaborates with other departments to assist in obtaining prior authorizations.
• Completes data review and reports on metrics/trends of authorization denials.
• Maintains an audit trail of changes to authorization requirements to assist with root cause analysis and support cause for appeals.
• Develops and maintains a strong working relationship with hospital departments and referring physicians to collaborate in obtaining information needed for successful appeal/reversal of authorization denial.
• Maintains a current knowledge related to insurance changes and requirements for prior authorization.
• Gathers data, performs a detailed review, and submits a report based on findings, as directed.
• Attends and participates in meetings, as needed.
• Performs other duties as assigned by the Director of Pre-Patient Access.

Minimum Qualifications

• Licensed as a Registered Professional Nurse in the State of Illinois
• Two (2) years of nursing work experience
• One (1) year of work experience in Utilization Management/Prior Authorization in a physician group, insurance company or management services organization
• Prior experience identifying trends in prior authorization and denial prevention, i.e., incomplete coding, lack of documentation

Preferred Qualifications

• Care management or medical insurance experience
• Bachelor’s degree in nursing from an accredited college or university
• One (1) year experience with electronic medical records (EMR)
• Prior experience using InterQual or Milliman criteria sets

Knowledge, Skills, Abilities and Other Characteristics

• Excellent verbal, written communication, and interpersonal skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
• Knowledge and proficiency with Microsoft applications and internet-based programs
• Strong interpersonal skills with the ability to establish strong working relationships
• Strong time management skills to prioritize assignments and meet the designated deadlines
• Ability to anticipate, recognize, and meet the needs of patients and families
• Ability to work in a team-based environment to accomplish goals and objectives
• Ability to demonstrate respect and sensitivity for cultural diversity in CCH work force and patient population
• Ability to critically think, problem solve and make independent decisions supporting the authorization process, including interactions with payer representative, physicians, and hospital case managers

• Competitive Salary
• Paid Time Off
• Health, Vision & Dental Insurance
• Health Savings Account (HSA)
• Flexible Spending Account (FSA)
• Short & Long Term Disability
• 401 (K) with company match
• Life Insurance