Prior Authorization Specialist

The Prior Authorization Specialist’s chief responsibility is to monitor incoming patient orders and gather information needed to complete the pre-authorization and scheduling of an order. S/he also evaluates and performs any other insurance-related assignments as needed. S/he must complete tasks in a timely and accurate manner to ensure appropriate patient treatment, patient satisfaction, timely scheduling and collection of hospital accounts receivable. May perform additional duties at the director or supervisor’s discretion.

Daily work includes but is not limited to heavy phone contact with payer organizations, physician offices, and patients to resolve precertification or preauthorization issues as needed prior to treatment. 

S/he cross-trains within the department to advance understanding of the hospital revenue cycle and support teammates, and performs duties in compliance with approved standards of care and practice as defined by GRMC.

ESSENTIAL FUNCTIONS

• Responsible for precertification and preauthorization for all scheduled patients and supports registration with urgent walk-in patients. Completes medical necessity process as needed.
• Supports registration with insurance verification and eligibility issues as needed.
• Researches, follows up, and resolves open and pending authorizations in a timely manner.
• Calculates cash estimates for patients on upcoming visits and procedures.
• Concisely and accurately documents all information and activity in the patient accounts. 
• Maintains clear communication with physicians’ offices and insurance companies. 
• Maintains strict standards of confidentiality as required by HIPAA and GRMC standards. 
• Participates in staff meeting and in-service programs.
• Performs duties with a compassionate, patient, and professional demeanor.
• Additional duties as assigned.

EDUCATION & TRAINING REQUIREMENTS

• High School Diploma or GED required.
• Progress towards college degree or prior clerical experience preferred.
• Professional telephone courtesy required.
• Understanding of patient, payer, and provider interactions as related to the prior authorization process.
• Familiarity with medical terminology including CPT and ICD-10 codes preferred.

WORK EXPERIENCE REQUIREMENTS

• 1+ years experience in precertification and/or preauthorization or 2+ years other relevant experience (e.g. other revenue cycle positions, medical assistant, nursing assistant).
• Experience working on multiple tasks while meeting deadlines.