Prior Authorization Specialist

About the Role

Assist Saunders Medical Center (SMC) Rural Health Clinic, Specialty Clinics, and other services with obtaining prior authorizations for patient procedures. The Prior Authorization Specialist provides detailed and timely communication to both payers and clinical partners to facilitate compliance with payer requirements and is responsible for documenting the appropriate information in patient records. This position 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 (EMR).
• Monitor trends for prior authorizations and communicate these with SMC clinic staff, providers, and the business office supervisor as appropriate.
• Appropriately 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.
• Keep up to date with prior authorization requirements and changes, sharing these as appropriate with department leaders.
• 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 to include 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 that may be required for reimbursement.
• Participate in Saunders Medical Center committees as approved by 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 quality, safety, security, and infection control programs that are mandatory, as well as those required by the department.
• Uphold confidentiality and HIPAA compliance at all times and report violations to the Privacy Officer.
• Understand and comply with the requirements of Saunders Medical Center’s Compliance Program, including the Code of Conduct and Compliance Policy.
• Participate in all education and training programs regarding compliance as required by Saunders Medical Center policy.
• Demonstrate personal traits of high-level commitment, motivation, team orientation, professionalism, trust, honesty, integrity, and respect for others.
• Other duties as assigned.

Requirements

• 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 authorizations 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.
• Maintain any certifications or licenses according to education.
• Ability to read, write, and follow written and oral instructions, with positive communication skills.
• Ability to deal tactfully with personnel, patients, visitors, and the general public.
• Ability to calculate at the level necessary to perform essential duties of the position.
• Ability to make independent decisions when circumstances warrant such action.
• Ability to interpret a variety of instructions furnished in oral, written, diagram, or schedule form.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• While performing the duties of this job, the employee must stand frequently.
• The employee must sit, reach with arms and hands, and occasionally lift up to 50 pounds.
• The employee must occasionally walk and climb or balance.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

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