Prior Authorization Coordinator

If you are an existing employee of South Shore Health then please apply through the internal career site.

Requisition Number

R-19622

Facility

LOC0020 - 143 Longwater Norwell143 Longwater Drive Norwell, MA 02061

Department Name

SMC Internal Medicine PB

Status

Full time

Budgeted Hours

36

Shift

Day (United States of America)

The Prior Authorization Coordinator is a Healthcare Professional responsible for submitting prior authorization requests to insurance companies on behalf of patients and providers, and managing the process of obtaining necessary approvals for medications, prescriptions, and other treatments ensuring timely access to care while adhering to insurance guidelines and compliance regulations. This role often involves communicating with patients, providers, and insurance companies to gather necessary documentation and follow up on pending requests. This role will work closely with the inter-professional teams at the South Shore Medical Center ambulatory clinics.

Essential Functions

• Patient information verification:
  
  

Reviewing patient medical records, confirming insurance eligibility, and verifying benefits to determine if prior authorization is required.

• Prior authorization request submission:
  
  

Completing and submitting accurate prior authorization forms to insurance companies, including detailed medical information, diagnosis codes, and treatment plans.

Request, track, and obtain prior authorizations from insurance carriers/third party authorization companies within a reasonable time frame.

• Communication with providers and patients:
  
  

Contacting healthcare providers to gather necessary clinical documentation and communicating with patients regarding the status of their prior authorization requests.

• Follow-up on pending requests:
  
  

Monitoring the status of prior authorization requests, reaching out to insurance companies to resolve any issues or delays, and notifying providers and patients of updates.

• Denial management:
  
  

Identifying reasons for denied prior authorization requests, appealing denials, and working with providers to address issues that may lead to denials.

• Compliance with regulations:
  
  

Staying updated on insurance company policies, payer guidelines, and healthcare regulations related to prior authorization.

• Data entry and record keeping:
  
  

Maintaining accurate patient records within the electronic health record system, including details of prior authorization requests and approvals.

Required Skills

• Strong administrative skills:
  
  

Ability to manage a high volume of tasks with attention to detail and accuracy.

• Medical knowledge:
  
  

Understanding of medical terminology, diagnosis codes, and common procedures.

• Insurance knowledge: Familiarity with different insurance plans, benefit verification, and prior authorization processes.
• Excellent communication skills:
  
  

Ability to effectively communicate with patients, providers, and insurance companies, both verbally and in writing.

• Problem-solving skills:
  
  

Identifying issues with prior authorization requests and finding solutions to address them.

Oversee and ensure proper process and workflow.

• Computer proficiency:
  
  

Ability to navigate electronic health records and insurance company portals to submit prior authorization requests.

• Workflow Creation Experience:
  
  

Creates proper workflows for tracking and managing prior authorization process.

Qualifications

• High School Diploma or GED preferred.
• Minimum of 3-5 years’ experience preferred in an ambulatory or medical office health care setting.
• Strong familiarity with medical terminology, medications, and health insurance processes.
• Prior experience with processing prior authorizations and reimbursement guidelines required.
• Exceptional organization, time-management, and communication skills.
• HIPAA regulations experience.
• Knowledge of Epic strongly preferred.
  
  

Mon - Fri variable hours.

Responsibilities If Required

Education if Required:

License/Registration/Certification Requirements

Basic Life Support (BLS) Certification - American Heart Association (AHA) (Including courses offered through SSH), INSTRUCTOR- Basic Life Support (BLS) - American Heart Association (AHA) (Including courses offered through SSH)