Prior Authorization Specialist

Position Description

Responsible for verifying insurance coverage and eligibility, and obtaining required pre-authorizations for medical procedures, treatments and services.

Major/Essential Functions

• Handle authorization process and obtain pre-certification approvals prior to service.
• Submit pre-authorization requests and follow up with payer to ensure timely approvals. Update resident providers and supervising faculty of delays related to pre-authorization.
• Assist providers with treatment plan assessment to determine if pre-authorization is required.
• Assist in the development and maintenance of a standardized workflow for the pre-authorization process.
• Provide instruction and guidelines on coding and pre-authorization processes to faculty, residents and staff.
• Assist in the preparation and submission of appeals for denied authorizations, including but not limited to providing additional information or documentation.
• Respond and follow-up to patient and insurance inquiries/correspondence in a timely manner and in accordance with departmental expectations/requirements.
• Provide leadership team with regular status updates on authorization and denials.
• Maintain accurate records and reports of pre-certifications request, approvals, and denials.
• Review assigned electronic health record (EHR) Work Queue's to ensure all errors are cleared and billing has been submitted in a timely manner, and in accordance with departmental expectations/requirements.
• Stay current with changes in coding guidelines, insurance regulations and insurance requirements.
• Assess and monitor Medicaid/CHIP billing guidelines and regulations while partnering with the Office of Institutional Compliance on corrective action plans related to billing compliance.
• Collaborate with revenue cycle team via weekly, biweekly, and/or monthly meetings (as directed) to review payment and denial trends.
• Collaborate with members of clinic administration on process improvement to help optimize the pre-authorization processes in the clinics.
• Communicate with patients regarding authorization requirements, status updates and financial responsibilities associated with approved or pending authorizations.
• Serve as a liaison between clinical providers and insurance payers to address authorization-related issues or inquiries effectively. Escalate matters of concern to leadership in accordance with departmental expectations/requirements.
• Remain current with all licensure, certifications and mandatory compliances and trainings required of this position.
• Adhere to all policies, procedures and practices (Regents Rules, TTUS, HSECEP OPs, etc.).
• Personally, and consistently, demonstrate, display and act in accordance with Texas Tech Health El Paso's Values (Service, Respect, Accountability, Integrity, Advancement, and Teamwork). Serve as a Value's leader while actively promoting and encouraging staff across the institution.
• Perform all other duties as assigned.

Preferred Qualifications

• PACS, CHAA or CMA certification.
• Previous experience providing support to multiple medical sub-specialties/clinics.
• Previous experience working in an academic medical/health sciences center.
• Bilingual in English and Spanish.
• Excellent communication (verbal and written) and interpersonal skills.
• Knowledge of basic medical terminology.
• Knowledge of CPT and ICD-10 coding.
• Familiarity with payer authorization processes.
• Ability to apply a strong attention to detail to work while meeting required deadlines, targets, goals, and/or metrics.

Pay Statement

Compensation is commensurate upon the qualifications of the individual selected and budgetary guidelines of the hiring department, as well as the institutional pay plan. For additional information, please reference the institutional pay plan website.

EEO Statement

All qualified applicants will be considered for employment without regard to sex, race, color, national origin, religion, age, disability, protected veteran status, or genetic information.

Required Qualifications

• Associate's degree plus one (1) year of experience directly related to the processing of prior authorizations; OR
• High school diploma or GED plus current certification as a Prior Authorization Certified Specialist (PACS), Certified Healthcare Access Associate (CHAA), or Certified Medical Assistant (CMA); OR
• High school diploma or GED plus three (3) years of experience directly related to patient registration, patient scheduling, patient billing/collections, and/or the processing of prior authorizations.

Jeanne Clery Act

The Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act is a federal statute requiring colleges and universities participating in federal financial aid programs to maintain and disclose campus crime statistics and security information. By October 1 of each year, institutions must publish and distribute their Annual Campus Security Policy & Crime Statistics Report (ASR) to current and prospective students and employees. To view this report, visit the TTUHSC Clery Act website.