Prior Authorization Specialist/Licensed Practical Nurse

JOB TITLE: Prior Authorization Specialist/Licensed Practical Nurse

JOB SUMMARY: The Prior Authorization Specialist is responsible for all aspects of the prior authorization process, which includes reviewing and interpreting medical record documentation for patient history, diagnosis, and previous treatment plans. Utilizes payer-specific approved criteria to determine medical necessity or the clinical appropriateness for the company's products. Submits pertinent demographic and supporting clinical documentation with authorization requests timely to avoid unnecessary delays in patient treatment. The Prior Authorization Specialist reports directly to the Medical Clinic Manager.

SPECTRA HEALTH EXPECTATIONS:

• Review and comply with regulatory standards.
• Strict adherence for privacy and confidentiality, for both patients and employees of Spectra Health
• Champion Spectra Health's organizational values of Compassion, Trust, Respect, Equity, and Inclusivity.
• Affirm Spectra Health's culture of safety by demonstrating actions and behaviors that consistently contribute to a positive and safe work environment for our employees and guests. (i.e., timely incident reporting, resolving hazards proactively, resolving privacy and security concerns, etc.).
• A positive approach to teamwork, building collaborative positive relationships throughout the organization in order to share knowledge and experience.
• Ability to work independently.
• Be part of the solution, supporting change and participating in activities to promote organizational leadership.
• Make decisions based on what's best for Spectra Health's patients.
• Attend mandatory trainings and attend at least 80% of departmental meetings.
• Adhere to all Spectra Health's policies and procedures and serves as a departmental champion of Spectra Health's Compliance Program activities.

ESSENTIAL JOB FUNCTIONS:

• Collecting all the necessary documentation, contacting the client for additional information and completion of the required prior authorization in order to proceed with testing and treatment, Including, but not limited to, imaging, in clinic procedures, diagnostic testing, rehab, orthotics and prosthetics, referrals, and medications.
• Complete, timely, and accurate identification and submission of prior and retro authorization requests to the payors.
• Interacts with clients, insurance companies, patients, and sales representatives, as necessary, to request prior authorizations.
• Responsible for documenting and tracking account activity, updating patient and claim information and demonstrates proficiencies with the diverse billing systems to ensure all functionalities are utilized for the most efficient processing of claims and identifies prior authorization trends and/or issues resulting in delayed claims processing from initial submission through final insurance determination.
• Provides the highest level of customer service to internal and external clients.
• Schedule lab work, tests, procedures, referrals, or surgeries according to standards; appointments.
• Completes and codes laboratory and radiology requests, obtaining waivers from patients as necessary.
• Complete training and perform CLIA waived lab tests as allowed by certification/license.
• Provides triage for urgent patient calls and discussion with provider and Identifies significant changes or high-risk situations in patient's condition and takes appropriate actions as evidenced in reporting and documentation.
• Prepares patients for exams and assists with procedures as provider requests.
• Maintains an efficient flow of patients.
• Answers telephone, routes calls, and takes accurate and complete phone messages for the provider and relays information in a prompt manner following policy.
• Provides patient/patient's family with appropriate education based on identified needs to optimize patient/patient's family understanding and documents response according to standard operating procedure.
• Completes all charting and documentation within the EHR of all authorized medication refills and instructions given, along with administration of medication(s).
• Notifies Medical Clinic Manager of any complaints, unsatisfactory outcomes, or special requests.
• Notify patients of lab reports when requested by provider.
• Prepare instruments for CSR.
• Check medications and supplies for outdates and communicate supply needs to appropriate staff to ensure timely restock of supplies.
• Other duties as assigned such as phlebotomy, scanning, performing EKGs.
• Basic knowledge of Microsoft Word, Microsoft Excel, Microsoft Outlook. Ability to work on local desktop and in remote desktop sessions. Basic computer hardware knowledge. Ability to gain proficiency in Spectra Health's organizational software programs including but not limited to electronic medical or dental records, practice management systems, and multiple web-site accounts.

JOB QUALIFICATIONS:

Required:

• Holds current valid North Dakota license as an LPN.
• Minimum of 2 years of customer service experience in the healthcare industry preferred.
• Minimum of 2 years of Epic software
• Proficiency in Medical Billing: ICD and CPT coding highly desired.
• Knowledge in Medicare and third-part payer regulations and guidelines highly desired.
• CPR/BLS certification is required or must be obtained within six (6) weeks of employment.

Preferred:

• One to two years clinical nursing experience, preferably in a clinic setting.

WORKING CONDITIONS: Work is performed in a clinical setting and requires some hands-on patient care. OSHA category: High risk. Job requires performance of tasks that involve exposure to blood, body fluids or tissue.

PHYSICAL REQUIREMENTS: The Licensed Practical Nurse/Certified Medical Assistant works in a clinical environment that requires the employee to be on the feet for long periods of time. This position requires the ability to communicate with patients and periodically might require the ability to lift and carry items (not more than 20lbs).

REMOTE WORK: The Prior Authorization Specialist position is not eligible for full-time or hybrid remote work. For more information about remote work, please see HR Policy 1.28 - Remote Work.

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

**Spectra Health provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, genetics, sexual orientation, or gender identity.

Salary : $19 - $25