Prior Authorization Specialist

Job Description

Job Description

Continuumrx is currently recruiting employees in Birmingham, Alabama to support our Acute Authorization and Verification Team!

Job Summary:

• The Verification Specialist - Specialty role is responsible for processing benefit verification of benefits for acute patients.
• The primary role of the Authorization Specialist is to review, process, and follow to completion the requirement of obtaining prior authorizations for services. This includes PBM authorizations.

Verification Specialist Roles and Responsibilities:

• Verifies benefit coverage and as appropriate, financial responsibility.
• Identifies out-of-pocket co-pays, deductibles, and co-insurance prior to services rendered in accordance with the insurance eligibility/coverage information provided by payor at time of insurance verification.
• Documents all patient interaction in EMR as a billing note.
• Serves as a resource and problem resolution expert for patients, Intake and Sales.
• As needed, verifies insurance coverage and eligibility through payor websites, E1 check, or by calling the payor directly. Document information in EMR and communicates as appropriate to team members.
• Assists with Ready To Bill (RTB) as appropriate.
• Performs other duties and special projects, as assigned.
• Complete understanding of confidentiality with respect to Company proprietary information as well as information concerning patient/client care; complying with all federal and state laws as apply to confidentiality of protected health information (PHI) and electronic protected health information (EPHI); and following HIPAA guidelines regarding readily identifiable protected health information.

AuthorizationSpecialist Roles and Responsibilities:

• Coordinates with the Intake Specialists and the Pharmacy Team to identify and process requests for services requiring Prior Authorization and/or Pre-Determination for services rendered.
• Reviews each request for Prior Authorization and insures that the proper supporting documentation and forms/documents are completed.
• Processes Prior Authorizations via Fax, computer or phone call as required by the specific payers.
• Maintains an organized process for documenting and tracking all requested prior authorizations.
• Maintains an organized process for timely follow-up and troubleshooting of all pending Prior Authorizations.
• Documents in the patient record all prior authorizations, expiration dates and other information as required.
• Communicates with the Revenue Cycle Team and Admission Specialists any prior authorization denials and insures prompt follow-up.
• Maintains a process to review newly accepted patients for a “second check” to prevent missing prior authorization requests.
• Effectively identify and communicate to supervisor when assistance is needed (including, but not limited to system function, training, etc.).
• Observes legal and ethical guidelines for safeguarding patient and company confidentiality (HIPAA).
• Understands and provides exceptional customer service to clients, patients, and payers.
• Exhibits a positive, courteous, respectful and helpful attitude to clients, co-workers, and management team.
• Promotes company culture by adhering to all policies and procedures.
• Adapts to and demonstrates the ability to deal with frequent changes in the work environment.
• Other tasks/duties as assigned.
• Complete understanding of confidentiality with respect to Company proprietary information as well as information concerning patient/client care; complying with all federal and state laws as apply to confidentiality of protected health information (PHI) and electronic protected health information (EPHI); and following HIPAA guidelines regarding readily identifiable protected health information.

Qualifications and Experience:

Required:

• 2 or more years of experience in healthcare reimbursement with focus on insurance verification and authorizations.
• Experience with coordination of benefits, including but not limited to HMO, PPO, TPA, state and federal payors; preferred but not required.
• Prior work in specialty or home infusion, homecare or related field; preferred but not required.
• Strong computer skills (Microsoft Word, Excel, PowerPoint)
• Exceptional communication - verbal and written
• Exceptional interpersonal skills
• Exceptional organizational and process skills
• Ability to work well under pressure, meet timelines, and completes assigned projects
• Exceptional critical thinking and problem solving skills
• Proven performance, history in related field Exceptional attention to detail and demonstrated results
• Exceptional track record of customer satisfaction