Prior Authorization Specialist - Clinic

The Pre-Authorization Specialist is primarily responsible for oversight in obtaining the required pre-certifications, pre-authorizations, and referrals for all services accurately and timely. Under the direction of the Revenue Cycle Manager, the employee will ensure that the processes within the department are functioning appropriately.

ESSENTIAL FUNCTIONS:

• Prioritize incoming authorization requests according to urgency.


• Generate, verify, and oversee the complete procedure authorization/referral process.


• Manages and resolves day-to-day issues pertaining to pre-authorization, as needed.


• Monitor provider network status and notify appropriate individuals of non-network status providers.


• Obtain authorization by fax, payer website or by phone and follow up regularly on pending cases.


• Notify appropriate departments for approvals and denials.


• Initiate and assist with appeals for denied authorizations.


• Notify and coordinate P2P (Peer to Peer) requests with the appropriate department.


• Confirm accuracy of CPT and ICD-10 diagnoses in the procedure order


• Contact patients as needed to discuss authorization status.


• Effectively maintain, monitor, and update payer medical policy guidelines to manage authorization requirements.


• Request, review, and submit necessary patient documentation as needed.


• Assists with patient scheduling and inquiries, as necessary.


• Effectively utilizes ICD 10, CPT, HPCPS, modifiers and/or other codes according to coding guidelines.


• Communicates effectively with provider and/or all appropriate parties regarding missing information such as CPT, diagnoses codes, documents, operative reports, etc. to ensure proper authorization processing.


• Communicates effectively with other departments regarding changes and/or updates with patient accounts and status.


• Manages the status of accounts and identify inconsistencies.


• Responds to billing inquiries.


• Uses downtime efficiently; is aware of team members workload.


• Communicates company goals, expectations, updates, and/or deadlines timely.


• Makes recommendations on workflow improvement as needed.


• Reports statistics as required.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Knowledge with in and out of network insurances, insurance verification, patient responsibility, and process for prior authorization.


• Familiarity with ICD-10 and CPT codes and procedures.


• Ability to review and understand patient medical documentation.


• Ability to independently identify and understand medical necessity requirements.


• Task-oriented and organizational skills; ability to complete tasks timely


• Detail-oriented focus; being careful about detail and thorough in completing work tasks.


• Ability to work independently and as a team.


• Ability to adapt with flexibility.


• Effective communication skills (written/verbal).

EDUCATION AND EXPERIENCE:

• High school diploma or GED


• Two (2) years of medical office or facility setting experience