Prior Authorization Specialist

About the Role

To assist Saunders Medical Center (SMC) Rural Health Clinic, Specialty Clinics, and other services with obtaining prior authorizations for patient procedures. This position provides detailed and timely communication to both payers and clinical partners to ensure compliance with payer requirements and is responsible for documenting the appropriate information in the patient's record. The role is under the supervision of the Care Coordinator Supervisor.

Responsibilities

• Contact patient insurance companies to obtain prior authorizations as indicated.
• Obtain benefit verification for cases as needed.
• Keep all online web portals active to ensure access is maintained for obtaining or verifying prior authorizations.
• Maintain records of all prior authorization statuses, actions, and outcomes in the electronic medical record.
• Monitor trends for prior authorizations and communicate these with SMC clinic staff, providers, and the business office supervisor as appropriate.
• Prioritize workload to ensure the most urgent cases are handled in a timely manner.
• Ensure timely and accurate insurance authorizations are in place prior to services being rendered.
• Stay updated with prior authorization requirements and changes, sharing them with department leaders as appropriate.
• Communicate regularly with other departments within SMC regarding prior authorizations and educate staff as needed.
• Develop and maintain working relationships with external agencies and providers who have specialty clinics at SMC regarding prior authorizations.
• Utilize customer service skills in engaging teams, customers, and insurers as needed.
• Provide documentation, including authorization numbers, CPT codes, diagnosis, and approval dates in the EMR, as well as reference numbers if no authorization is required.
• Send medical records pertaining to authorizations as needed.
• Understand the billing process to identify and communicate codes required for reimbursement.
• Participate in Saunders Medical Center committees as approved by the supervisor.
• Maintain a professional environment.
• Participate in quality assurance and improvement as assigned.
• Perform all duties within legal limitations as properly authorized, delegated, or assigned.
• Practice proper fire, safety, and disaster procedures as set forth by SMC.
• Participate in all mandatory quality, safety, security, and infection control programs.
• Uphold confidentiality and HIPAA compliance, reporting violations to the Privacy Officer.
• Comply with Saunders Medical Center’s Compliance Program requirements, including the Code of Conduct and related policies.
• Participate in all required education and training programs regarding compliance.
• Demonstrate personal traits of commitment, motivation, professionalism, trust, honesty, and respect.
• Perform other duties as assigned.

Qualifications

• Minimum of two years of experience in pre-authorizations or insurance verification with demonstrated knowledge of health insurance plans.
• Experience communicating with insurance companies and awareness of prior authorization processes preferred.
• Knowledge of medical terminology.
• Demonstrated ability to efficiently organize work and maintain a high level of accuracy and productivity.
• Excellent typing and computer skills.

Skills

• Ability to read, write, and follow written and oral instructions.
• Positive communication skills, including the ability to deal tactfully with personnel, patients, visitors, and the general public.
• Mathematical skills sufficient for essential duties.
• Ability to make independent decisions and interpret various instructions.

Physical Demands

The employee must frequently stand, sit, reach with arms and hands, and occasionally lift up to 50 pounds. Occasional walking, climbing, or balancing is required.

Work Environment

Typical medical clinic office environment. Attendance is essential for a successful working environment.