Purchased and Referred Care Authorization Specialist

Essential Duties and Responsibilities

• Supports the organization’s mission and goals, quality standards, and patient-centered medical home philosophy.
• Embraces KANA’s culture of serving the whole person through our provision of services.
• Incorporates KANA’s core values of Courtesy, Caring, Respect, Sharing, and Pride in all activities and decisions.
• Supports the organization’s mission and goals, quality standards, and patient-centered medical home philosophy.
• Embraces KANA’s culture of serving the whole person through our provision of services.
• Incorporates KANA’s core values of Courtesy, Caring, Respect, Sharing, and Pride in all activities and decisions.
• Reviews referrals to determine PRC eligibility.
• Utilizes Cerner to verify service need, referral location, patient eligibility, and required documentation.
• Counsels patients on insurance options and eligibility.
• Conducts research to confirm eligibility for each referral.
• Adheres to all Finance requirements and processes for purchase and payment processing.
• Notes alternate insurance coverage to bill prior to KANA (payer of last resort).
• Includes stipulations for patient action (e.g., Medicaid application requirements).
• Applies limits to requisitions, including: Dates of service, Number of visits, and Value of visits.
• Prepares denial documentation as applicable.
• Uploads approval or denial letters into Cerner and attaches to the appropriate referral.
• Reassigns completed referrals with documentation to the Referred Care Coordinator for further processing.
• Records all decisions in patient files in Cerner.
• Communicate with Patient Benefit Coordinators regarding uninsured patients.
• Participates in relevant training related to PRC, billing, and coding.

Requirements

• A high school diploma or general education degree (GED)
• Two years’ experience working with the public in an office setting
• Equivalent combination of education and experience
• Familiarity with federal, state and local resources available to meet the health and social needs of patients
• Knowledge of medical billing procedures, medical terminology, HIPAA, and other state and federal regulations governing healthcare practices