UPMC Regional Orthopaedics is hiring a full-time Authorization Specialist for their Hermitage office. This is a Monday-Friday, daylight position. No Weekends or Holidays!
Responsibilities: - Prior authorization responsibilities.
- 1. Reviews and interprets medical record documentation for patient history, diagnosis, and previous treatment plans to pre-authorize insurance plan determined procedures to avoid financial penalties to patient, provider, and facility.
- 2. Utilizes payor-specific approved criteria or state laws and regulations to determine medical necessity or the clinical appropriateness for inpatient admissions, outpatient facility, office services, durable medical equipment, and drugs in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury, or disease.
- 3. Ensures accurate coding of the diagnosis, procedure, and services being rendered using ICD-9-CM, CPT, and HCPCS Level II.
- 4. Provides referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive nonclinical administrative time required of providers.
- 5. Submits pertinent demographic and supporting clinical data to payor to request approval for services being rendered.
- General responsibilities:
- 1. Maintains compliance with departmental quality standards and productivity measures.
- 2. Works collaboratively with internal and external contacts specifically, Physician Services and Hospital Division, across UPMC as well as payors to enhance customer satisfaction and process compliance, ensuring the seamless coordination of work and to avoid a negative financial impact.
- 3. Utilizes 18+ UPMC system and insurance payor or contracted provider web sites to perform prior authorization, edit, and denial services.
- 4. Utilize authorization resources along with any other applicable reference material to obtain accurate prior authorization.
- Retrospective authorization responsibilities
- 1. Resolves basic authorization edits to ensure timely claim filing and elimination of payor rejections and or denials.
High School diploma or equivalent with 2 years working experience in a medical environment (such as a hospital, doctor's office, or ambulatory clinic) OR an Associate's degree and 1 year of experience in a medical environment required. (Bachelor's degree (B.A) preferred) Completion of a medical terminology course (or equivalent) required Skills Required: Knowledge and interpretation of medical terminology, ICD-9, and CPT codes. Must be proficient in Microsoft Office applications Excellent communication and interpersonal skills. Ability to analyze data and use independent judgment. Skills Preferred: Understanding of authorization processes, insurance guidelines, third-party payors, and reimbursement practices. Experience utilizing a web-based computerized system.
Licensure, Certifications, and Clearances:
UPMC is an Equal Opportunity Employer/Disability/Veteran
UPMC has a Center for Engagement and Inclusion that is charged with executing leading-edge and next-generation diversity strategies to advance the organization’s diversity management capability and its national presence as a diversity leader. This includes having Employee Resource Groups, such as PRIDE Health or UPMC ENABLED (Empowering Abilities and Leveraging Differences) Network, which support the implementation of our diversity strategy.
Annual
