What are the responsibilities and job description for the Prior Authorization/Referral Specialist position at United Hospital System?
POSITION PURPOSE
A Prior-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 Prior-Authorization/Referral Specialist provides detailed documentation and communication with both payors and clinicians to obtain prior-authorizations. Obtains clinical information to support medical necessity.
MINIMUM EDUCATION REQUIRED
High School or GED
MINIMUM EXPERIENCE REQUIRED
1-3 years
LICENSES / CERTIFICATIONS REQUIRED
Formal education beyond high school in Business or Healthcare or equivalent experience preferred.
KNOWLEDGE, SKILLS & ABILITIES REQUIRED
Experience in prior authorization/referrals, patient registration, insurance verification and health insurance plans.
Knowledge on online insurance prior-authorization process and working with various payors.
Excellent customer service and computer 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.
PRINCIPLE ACCOUNTABILITIES AND ESSENTIAL DUTIES
Verifies 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.
Manages and resolves assigned departmental workqueues.
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 reviews, when required.
Communicates with patients, clinicians, financial counselors and other as necessary to facilitate the authorization process.
Completes accurate documentation in 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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