Prior-Authorization Specialist

Reports to the VP Patient Access. Responsibilities include evaluating designated referred services for authorization needs based on government and commercial payor requirements and disseminating all clinical and coding supporting documentation to complete the authorization process and ensure appropriate reimbursement. Mission, Values and Service Goals Mission: We deliver outstanding care, inspire health, and connect with heart. Values: Trust, Respect, Integrity, Compassion. Service goals: Personally connect, keep everyone informed, be on their team. Prior Authorization Specialist duties in accordance with established policies and procedures by Serving as primary contact and resource for all designated prior authorization needs. Identifying, collecting, and coordinating clinical documentation to support the qualification of ordered services. Evaluating orders for insurance coverage and authorization requirements. Ensuring carrier process requirements are met within contracted guidelines and timeliness. Ensuring proper testing is done. Utilizing tools in accordance with the provider's desire and the testing criteria and guidelines, including both insurance and modality ordering guidelines. Reviewing and complying with additional requests. Validating completed authorizations to ensure the authorization corresponds with ordered service, code, time frame, and provider. Supporting the appeal process by coordinating resolution expectations with provider and authorization agent. Maintaining standardized records to allow effective coordination, tracking, and reporting of department actions and metrics. Advocating for the customer by recognizing when to dispute a non‑desirable outcome regarding PA approval. Disputing and negotiating, when necessary, on behalf of BHS and the customer for a positive prior authorization outcome. Providing exceptional customer‑centric service during every encounter with patients, families, and associates. Using critical thinking skills to make decisions, identify problems, create solutions, and help implement change, escalating concerns when necessary. Participating in performance improvement, following established work systems, identifying deviations or deficiencies, and communicating problems to supervisor or manager. Prioritizing work in an effective manner. Working at a fast pace and maintaining accuracy. Understanding the flow and rhythm of each task and connecting each resulting convenient, connected, and coordinated care. Using multiple software platforms (EMRs, insurance websites, referral database, scheduling software, etc.) to conduct tasks for patient care. Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by Assisting others and/or accepting additional duties. Enhancing professional growth and development through in‑service meetings and educational programs as approved. Maintaining up‑to‑date knowledge and staying abreast of changes and updates as they occur, including insurance, department, and process changes. Organizational Responsibilities Attends and participates in department meetings and is accountable for all information shared. Completes mandatory education, annual competencies, and department specific education within established timeframes. Completes annual employee health requirements within established timeframes. Maintains license/certification, registration in good standing throughout fiscal year. Direct patient care providers maintain current BCLS (CPR) and other certifications as required by position/department. Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self. Adheres to regulatory agency requirements, survey process, and compliance. Complies with established organization and department policies. Available to work overtime, additional shifts, and schedules when required. Commitment to Beacon's six‑point Operating System, referred to as The Beacon Way Leverage innovation everywhere. Cultivate human talent. Embrace performance improvement. Build greatness through accountability. Use information to improve and advance. Communicate clearly and continuously. Education and Experience Associate’s degree in Business or Health Care related field and one year medical authorization or related experience; or, in lieu of a degree, high school diploma or equivalent and three years medical authorization or related experience. Preferred: Medicare Assistant Program completion and certification exam or equivalent medical office experience. Knowledge of medical terminology, ICD‑10, CPT, prior authorizations, third‑party payors and prior authorization processes. Working knowledge of Microsoft Office: Outlook, Excel, and Word. Knowledge & Skills Well‑developed communication skills to communicate effectively and clearly with internal and external contacts. Analytical skills necessary to solve problems and interpret data. Promotes collaboration and innovation in clinical services to ensure an interdisciplinary approach to improving healthcare delivery and the quality of patient care. Tactful handling of patient problems of a highly personal and confidential nature. Professionalism maintained during potentially frustrating interpersonal situations. High knowledge of CPT and ICD‑10 codes. Working knowledge of referral and insurance network guidelines to ensure referral scheduling aligns with customer insurance rules and regulations. Understanding of payor requirements to navigate the authorization process via website, fax, or phone. Staying up‑to‑date with insurance changes and updates. Analytical skills to apply knowledge and evaluate clinical information to resolve denials through complex appeal processes. Strong customer service, communication, organizational, and analytical skills. Working Conditions Assigned hours, days, and shift may change based on departmental or organizational needs. May need to travel to other Beacon locations and/or work evening hours. Work space frequently congested by other personnel. Constant exposure to noise and distraction. Physical Demands Requires physical ability and stamina to perform essential functions of the position. Requires sitting for long periods in front of a computer monitor. #J-18808-Ljbffr