Prior Authorization Specialist
This job profile is not included in a recognized pathway.
Description
Responsible for obtaining pre-certifications and pre-authorizations for procedures, tests, medications, and scheduling appointments for patients. Responsibility includes working cohesively and collaboratively with providers and clinical teams to ensure patients prior authorizations are completed in a timely manner and scheduled in a convenient manner for the patients.
Tasks
- Receives messages from providers, nurses, and clinical team members when a prior auth is needed and works through the prior auth process with insurance companies in a timely manner.
- Contacts insurance companies to verify patient’s insurance eligibility, benefits, and requirements.
- Obtains, tracks, and follows up on pending authorizations and documents status, auth numbers, and prior auth details accordingly in the EHR.
- Documents and communicate insurance changes amongst team members as needed. Updates insurance information in EHR.
- Communicates closely with the clinical team, providers, and the patient with prior auth approvals, denials, next steps, and scheduled appointments. Works closely with providers and clinical teams on denials and submits additional information and documentation necessary for approval.
- Clearly documents all communications with providers and patients in a professional standardized manner using suitable EHR documentation standards.
- Works closely with clinical teams and providers on prior authorization processes, template use, and regulatory requirements and changes as needed.
- Trains clinical teams and providers on prior authorization processes necessary for approved statuses.
- Maintains a level of productivity suitable to ensure prior authorizations are consistently managed in a timely manner.
- Other duties as assigned. Must be willing to help all locations with prior authorization needs.
Qualifications / Education
EDUCATION/EXPERIENCE
- High School Diploma or equivalent required.
- 1-5 years of healthcare experience and medical terminology preferred.
- Must have excellent written and verbal communication and interpersonal skills.
- Customer relation skills, the ability to organize, and attention to details are essential skills for the position.
- Requires good judgment, the ability to problem solve, and must be able to multi-task and work effectively in a team environment.
- Must have good reading and computer skills.
