Outpatient Prior Authorization Specialist

FULLTIME POSITION

• 36-40 hours/ week
• Monday – Friday

RESPONSIBILITIES:

The Prior Authorization Specialist is responsible for obtaining eligibility, benefits, authorizations, pre-certifications in the outpatient setting. This role will also support and collaborate with the Utilization Management Team. Telephonic and online support of insurance prior authorizations, routine authorizations, and denials. This role is a primary documentation source for access and billing and will work with insurance companies to appeal denials.  Interacts in a customer-focused and compassionate manner to ensure patients and their representative needs are met.    

Other responsibilities include:

• Obtains daily work from multiple work queues to identify what is required.
• Completes eligibility check and obtain benefits through electronic means or via phone contact with insurance carriers or other agencies when necessary/requested provide initial clinical documentation.
• Responsible for obtaining medication authorizations based on provider prescribing.
• Collaborate with pharmacy on medication authorizations to ensure coverage and cost of medication to serve the patient needs.
• Review documentation timely from referring provider to meet the needs of the payee. If necessary, will contact the provider or their office for additional information regarding the order
• Verifies diagnosis codes on order are accurate and reimbursable / payable via communication with HIM.
• Works closely with the Business Office on denials for medical necessity or for no authorization, writing appeal letters as needed.
• Works with insurance companies, providers, coders, and Utilization Review to appeal denied claims.
• Initiates pre-certification process with provider, or insurance companies and obtains pre-cert/authorization numbers.
• Perform follow-up calls as needed until verification/pre-certification process is complete
• Thoroughly documents information and actions in all appropriate systems.
• Notifies and inform UR and other related departments of authorization information to insure timely concurrent review.
• Works with insurance companies to obtain retroactive authorization when not obtained at the time of service.
• Monitor and track patient authorizations, watching closely for any expired dates.
• Always safeguard and preserve the confidentiality of records in accordance with hospital department policy.

POSITION REQUIREMENTS:

• Associates Degree
• 1-3 years of experience in a hospital, medical office/clinic, or insurance company.
• Knowledge of Medical Terminology is required.
• Experience interacting with patients and a working knowledge of a 3^rd party payers and collections is preferred.
• Prior experience with verifications and payer benefit and eligibility systems is preferred.

BENEFITS

• Health Insurance, shared
• Dental and Vision Insurance
• 1.5 x annually salary life insurance, employer paid
• Short Term Disability, employer paid
• Long Term Disability, employer paid
• Retirement 403(b), 50% company match (maximum 3% match)

Stewart Memorial Community Hospital and all affiliated organizations is an Equal Opportunity Employer (EOE) and prohibits discrimination in employment on the basis of race, creed, color, religion, national origin, age, sex, pregnancy, disability, genetic information, status as a U.S. veteran, service in the U.S. military, sexual orientation, gender identity or expression, associational preferences, or any other classification that deprives the person of consideration as an individual.