Prior Authorization Specialist

Patient Services Specialist

The Patient Services Specialist plays a vital role in ensuring timely and accurate patient access to medical services by managing the prearrival prior authorization services. This position enhances patient access to care by ensuring all scheduled medical service requests and referrals are financially cleared prior to the date of service provision through the performance of insurance eligibility validation, plan benefit verification, and any related financial clearance, prior authorization, and pre-determination processes.

Monument Health offers competitive wages and benefits on qualifying positions. Some of those benefits can include:

• Supportive work culture
• Medical, Vision and Dental Coverage
• Retirement Plans, Health Savings Account, and Flexible Spending Account
• Instant pay is available for qualifying positions
• Paid Time Off Accrual Bank
• Opportunities for growth and advancement
• Tuition assistance/reimbursement
• Excellent pay differentials on qualifying positions
• Flexible scheduling

Universal Essential Functions:

• Collaborate with healthcare providers, clinical staff, and various departments throughout Monument Health as well as with the patient to secure necessary authorization for services while maintaining compliance with all regulatory requirements.
• Accurately verify patient insurance eligibility and benefits coverage, utilizing tools such as Electronic Health Records (EHR), add-on software, direct payer websites, and telephone or fax communications to ensure accurate reimbursement and compliance.
• Assess service requests to determine the need for pre-certification, pre-authorization (procedure or medication), or referrals, and communicate effectively with relevant stakeholders to secure approvals prior to the date of scheduled services.
• Maintain a strong working knowledge of various insurance payers, payer plans, and program contract requirements to facilitate appropriate insurance verification and authorization processes.
• Continuously meet competency requirements to sustain the necessary skills, knowledge, and abilities for role-specific functions, while adhering to productivity and quality performance standards.
• Create a positive service experience by being polite, compassionate, and professional with all internal and external customers.
• Document pre-authorization information accurately in the EHR system, ensuring that services scheduled by internal and external providers meet all financial clearance criteria and have approved authorization in the time allowed by the payers and programs to prevent denial or penalty assessment.
• Engage with departments and clinical staff to communicate the need for pre-authorizations or referrals promptly, working to prevent delays in patient care. May include requests for assistance with managing appeals as well as the facilitation and coordinating peer-to-peer reviews when needed.
• Identify high-risk requests that may require financial assistance and counseling and assist patients by providing guidance on available resources, financial assistance, or payment arrangements.
• Advocate for patients and providers by addressing challenges related to pre-authorization approvals and denials, working closely with leadership to resolve issues and ensure compliance with financial clearance policies.
• Provide backup support for Patient Admissions and Registration as needed
• All other duties as assigned.

Essential Functions for Medication Authorization and Assistant Specialist:

• Confirm prescription coverage and coordinate prior authorization, including collecting and submitting required clinical documentation (i.e. provider notes, labs and treatment history)
• Stay up to date on patient assistance programs and guide patients through required application documentation.
• Coordinate with providers and nursing staff to obtain required signatures and documentation from patients and providers
• Serve as a patient advocate by regularly communicating with pharmaceutical companies, providers and patients.
• Act as primary contact for patient inquiries about medication authorizations and assistance programs.
• Monitor assistance medications to ensure timely delivery and continuous patient access.
• All other duties as assigned.

Required:Education - High School Diploma/GED Equivalent in General Studies Preferred:Experience - 1+ years in Health Care Services, Customer Service, Patient Scheduling, Patient Billing Experience Education - Associates degree in Healthcare Related Field

Physical Requirements: Sedentary work - Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time.

Job Category: Patient Services

Job Family: Patient Support

Make a difference. Every day.

Monument Health is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected Veteran status.