Medication Prior Authorization Specialist

Job Summary

The Medication / Procedure Prior Authorization Specialist at Sheridan Memorial Hospital validates patients' health care benefits and obtains authorization for medications, equipment, and procedures. Responsibilities include contacting insurance companies, verifying physician orders, and maintaining communication with providers and patients.

Responsibilities

• Obtains pre-authorizations/pre-certification per payer requirements for services and ensures authorization information is documented appropriately.
• Verifies physician orders are complete, determines CPT, HCPCS, and ICD-10 codes for proper authorization.
• Understands and communicates insurance co-pays, deductibles, co-insurances, and out-of-pocket expenses for point of service collections.
• Maintains communication with providers, clinical staff, and patients regarding authorization status.
• Remains current with insurance requirements for pre-authorization and provides education within the departments and clinics on changes.
• Aid team members in maintaining turnaround times.
• Account for internal control responsibilities in line with the department objectives.
• Handle Protected Health Information in a manner consistent with HIPAA.
• Respond to inquiries using multiple methods of communications.
• Suggest improvements and participate in organized efforts to improve service levels.

Qualifications

• High school graduate or equivalent, required.
• Knowledge of CPT, HCPCS, and ICD-10 codes preferred.
• Medical terminology required.
• Certified Pharmacy tech, preferred.
• 3-5 years of experience working in a hospital, doctors office, or pharmacy setting.
• 1-2 years procedure and/or medication authorization experience required.

Additional Skills

• Have working knowledge of CPT codes and Diagnostic Codes.
• Working knowledge of financial responsibility from an insurance perspective.
• Effective presentation and response to questions from providers, clinical staff, payors, and patients.
• Solve practical problems and deal with a variety of concrete variables.
• Interpret instructions and respond to questions.
• Proficient with MS Office Suite including Word and Excel.
• Proficient with the Cerner EMR system.
• Handle conflict.
• Excellent time management and organization skills with attention to detail.
• Demonstrate critical thinking, creativity, and problem-solving abilities.
• Maintain confidentiality.
• Write clearly and informatively.
• Cope with stressful situations and maintain a calm and professional demeanor.
• Exercise good judgment to handle situations appropriately.
• Use online resources and tools efficiently.
• Multi-task using several systems and multiple monitors at the same time.
• Independently and effectively research when additional information or guidance is needed.