Prior Authorization Specialist

About Us:

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals.


We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.


JOB SUMMARY:

ESSENTIAL DUTIES AND RESPONSIBILITIES:
Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member's performance objectives as outlined by the Team Member's immediate Leadership Team Member.

• Determine if an authorization from payer is required for pre-registered outpatient diagnostic and surgical services by utilizing online resources or phone calls to the specific payer.
• If an authorization/referral is not on file, rep will escalate such cases to the scheduling physician to obtain approval or gather clinical data to submit for authorization.
• Submit authorization requests via phone or online resources to obtain approval for requested services, including gathering and submitting clinical data as requested by insurance companies.
• Complete the first pass medical necessity check if task has not been completed.
• Follow up with physician offices to obtain additional diagnosis and revised scripts if the medical necessity check fails. May follow up with patient, if needed.
• Will follow client scripting guidelines and for patient/physician outreach in compliances with HIPAA and patient satisfaction standards.
• Meet or exceed productivity guidelines to ensure engagement sustainability.
• Other duties as assigned.

REQUIREMENTS:

• High School Diploma or GED equivalent
• Healthcare experience and familiarity with medical terminology
• Knowledge of multiple specialty and prior authorization processes preferred.
• Knowledge of revenue cycle process
• Ability to handle multiple priorities to ensure timeliness of all deliverables
• Basic computer skills
• Familiarity with insurance carrier websites and processes, including claim resolution requirements
• Ability to work effectively in a remote environment

PHYSICAL DEMANDS:
Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.
A job description is only intended as a guideline and is only part of the Team Member's function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.