Prior Authorization Specialist

SUMMARY

Determines which patient services have third party payor requirements and is responsible for verifying eligibility, obtaining insurance benefits and ensuring prior authorization requirements are met prior to the delivery of tests, treatments, and medications

DUTIES/RESPONSIBILITIES (include but are not limited to the following)

• Reviews and processes all assigned prior authorization requests to completion. Diligently reviews patient health care data, diagnostic testing and treatment information for completeness for insurance requirements and prior authorization process.
• Communicates with providers, and clinical staff as needed to obtain and understand clinical documentation requirements. Provide required clinical documentation to payers via phone, faxed forms, and/or website.
• Maintains documentation of authorization approvals and denials, including authorization numbers and associated codes, dates, and other relevant data
• Communicates effectively with clinical staff, payor representatives, and providers

• Recommends process improvements for increased efficiencies

EDUCATION AND/OR EXPERIENCE

• Minimum (2) years experience in an hospital setting required, prior authorization experience preferred
• Knowledge of medical terminology, CPT and ICD-10 codes
• Must demonstrate consistent professional conduct and meticulous attention to detail
• Must possess excellent verbal and written communication skills as well as interpersonal skills with patients, staff and other healthcare professionals
• Critical thinking skills and a positive attitude

SKILLS AND ABILITIES

• Must be proficient with computer applications necessary for effective management of all scheduling processes.