Prior Authorization Specialist

Essential Functions/Responsibilities:

• Answer calls from patients and physician offices using exemplary customer service skills.
• Accurately enter required information, non-clinical and clinical, into computer database.
• Review clinical data matching it against specified medical criteria and follow established procedures for authorizing request for further review.
• Review incoming orders for completeness to determine if procedure ordered will be covered by insurance (in some cases, pre-certification is not warranted).
• Complete follow-up with physicians for orders still waiting for documentation.
• Contact physicians offices to obtain missing documentation to complete orders.
• Works with patients insurance companies to pre-certify/authorize procedures as ordered by the referring physician.
• Contact ordering physician with update if procedure is denied and assist with scheduling peer to peer reviews, if needed.
• Once order is complete, contact patient to confirm receipt of order and inform patient he/she will receive a scheduling call once insurance has been approved.
• Monitor pre-certification status to ensure timely processing and completion.
• Log order into the appropriate authorization spreadsheet and schedule procedure once approved.
• Maintain patient confidentiality as defined by state, federal and company regulations.
• Establish effective rapport with other employees, professional support service staff, customers, clients, patients, families, and physicians.
• Actively support departmental and corporate strategic plans and ensure successful implementation.
• Maintain cooperative working relationships with all clinics and providers.

Qualifications

Qualifications:

• Six months of previous experience in medical prior authorization. Will train the right person
• Knowledge of CPT and ICD-10 codes.
• Familiarity with medical terminology.
• High School Education or GED.
• Ability to interact with patients, insurers, and office team members in a responsible, professional, and ethical manner.
• Must be able to function effectively in a team-oriented environment.
• Must be able to work independently with limited direction.
• Must be reliable and demonstrate sound judgment and initiative.
• Able to work in a high volume/fast-paced environment.