Summary

Responsible for performing benefits verification and prior authorization functions with insurance carriers to ensure optimal reimbursement for high cost medications, surgeries and procedures, within an established time frame, for patient cases submitted to Patient Financial Services.

Responsibilities

Ensures correct referral form is completed for patient¿s plan. Reviews referral for accurate information prior to authorization to include patient provider identification information, clinic or procedure requested, and appropriate CPT-4 /billing codes. Contacts clinic to obtain additional information as needed.
Assists with medical necessity documentation and clearance to expedite approvals and ensure that appropriate follow-up is performed.
Collaborates with other departments, clinics, and procedures areas to assist in obtaining authorization/pre-certifications in a cross functional manner.
Contacts plans to extend authorization dates, obtain additional visits and urgent/priority authorizations/pre-certifications, as needed.
Notifies clinic/procedure area, Nurse Navigator, Providers and/or patients to inform them of the authorization denials. Obtains additional clinical information for denials and submits appeals to the plan for further consideration.
Completes documentation of referrals in software to include the authorization number, number of visits, and the authorization period (dates) to ensure claims are paid in a timely manner.
Utilizes software to process and track referrals and submit medical records to insurance carriers to expedite prior authorization processes.
Creates patients¿ records and accounts and ensure that pre-authorization information is properly updated.
Secures patients¿ demographics and medical information and ensures that all procedures are in sync with HIPPA compliance and regulation.

Other duties as assigned.

Career Type: Support

Individual contributors who support operational, functional or business strategy through tactical support of daily activities (clerical, administrative, technical). The majority of time is spent in the delivery of front line services or activities, typically under direct supervision.

Works to deliver day-to-day objectives with impact typically limited to particular job area and/or department

Makes minor adjustments to work methods to solve problems that are often routine and typically exist in current work processes and systems. Changes often require higher-level approval

Requires knowledge of operational, functional, and/or business systems and practices

Competencies

Leadership & Talent Management

May provide guidance, helping to train and review work of entry level employees

Organizational Impact

Delivers on day-to-day objectives with direct impact on team/unit results with some supervision
Daily challenges are typically of a routine nature, but may at times require interpretation or deviation from standard procedures

Communication & Influence

Communicates information that requires explanation or interpretation of moderate importance to the team/unit

Knowledge & Experience

Requires broad knowledge of operational, functional, and/or business systems and practices, typically obtained through some experience, education, or vocational training

Degree

No advanced education is typically required

Years of Experience

>3 and

Education Requirements

HS/GED High School Diploma or GED.

Preferred

None

Required Certifications / Licensure

None Preferred Certifications / Licensure

None

Equivalent Education And/or Experience

None

Parkland Health jobs

Prior Authorization Specialist