Prior Authorization Specialist II

JOB SUMMARY

Under the guidance of the Supervisor/Manager of Patient Access and Director of Revenue Cycle, our Prior Approval Specialist level II will oversee the process of collecting all necessary documentation needed for approval of services in regards to Pharmacy and Oncology services as well as diagnostic services.  They will help guide all departments of the hospital on all requirements for services in regard to prior authorization of services such as diagnostic testing, injections, procedures, medication needs and any other requirement needed to help assist the Revenue cycle in correct reimbursement. Will exhibit excellent customer service skills, and effective communication skills.  Will be responsible for maintaining education, and assisting with communicating new changes.  Will be able to preform all aspects of the job.  Strives for superior performance by consistently providing a product or service to leadership and staff that is recognized as ultimately contributing to the patient and family experience.  Recognizes and demonstrates understanding of patient and family centered care. 

PRIMARY JOB RESPONSIBILITIES

1. Verifies patient’s insurance benefits, eligibility, network status and can advise a patient if any issues or concerns.
2. Ability to submit and obtain insurance authorizations, understanding the payee’s requirements and time lines. Including Global needs, STAT and Urgent authorizations for testing.
3. Re-authorizes prior authorizations for extension of service, including validating insurance changes or updates.
4. Can relay the Peer-to-Peer process to the provider with an explanation of what is needed.
5. Ability to reach out to the Provider for additional documentation, update medication needs and ability to review the chart.
6. Understands CPT codes and ICD-10 codes.
7. Tracks patient’s referrals with the verification of diagnosis code, and procedure to be sure that this reimbursable by the payer.
8. Participates in and sets up training programs and educational activities as indicated.
9. Communicates well with all team members as needed to keep up to date  on patients care.
10. Remains well verse in all computer applications pertaining to job duties.
11. Completes work within authorized time to assure compliance with department standards. 
12. Demonstrates flexibility in response to unexpected changes in patient volumes, staffing and scheduling needs.
13. Maintains confidentiality of all information.
14. Maintains a well-organized environment to work at maximum efficiency.
15. Willingness to cross train within the department to effectively assist and understand other job functions as needed.
16. Maintain Productivity Stats and be able to report daily.
17. Manage Free drug and White bagged drug list including but not limited to:  patient enrollment and reenrollment, renewing prescriptions, scheduling the delivery of medications, cancelling appointments if medications are not arriving on time, working with new patients as they are added.
18. Work with the Patient Financial department on any billing issues or needs as they arise.
19. Assist with Appeals on denied claims or services.
20. Enroll patients with assistance programs to help provide Free drugs or discounted drugs. Includes:  grants, copay cards, free drug programs.
21.  Attend weekly meeting in regards to medication in regards to authorization updates, coverage, denials, coverage or claim issues.
22. Demonstrates knowledge of and supports hospital mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality statements, corporate compliance plan, customer service standards, and the code of ethical behavior.

DEPARTMENTAL AND ADDITIONAL JOB RESPONSIBILITIES

1. Special Projects as assigned by Supervisor/Manager or Director of Revenue Cycle
2. Other duties as assigned

JOB SPECIFICATIONS

EDUCATION (List required, and preferred if applicable)

1. Bachelor’s degree preferred.
2. Medical Terminology preferred.
3. Ability to navigate a patient’s chart within the EMR.
4. Previous experience with Prior Authorizations preferred.
5. Medical Assistant certification preferred.

EXPERIENCE

1. Minimum one years’ pre certification experience preferred, particularly for CPT, HCPC and ICD-10 codes
2. Excellent phone and customer service skills.
3. Knowledge of Health insurance plans including benefits, and authorizations.
4. Ability to effectively listen and solves problems quickly.
5. Experience with Oncology, and Pharmacy preferred.

ESSENTIAL PHYSICAL ABILITIES/MOTOR SKILLS

1. Able to travel independently throughout all Memorial Healthcare facilities.
2. Small motor skills required for operating modern computer, office, and telephone equipment as utilized by Memorial Healthcare (MHC).
3. Ability to sit or stand for long periods of time.

ESSENTIAL TECHNICAL ABILITIES

1. Proficiency using modern office, computer and telephone equipmentas used by Memorial Healthcare.
2. Ability to entre and retrieve data from computers.
3. Ability to pull reports and understand the data.

ESSENTIAL MENTAL ABILITIES

1. Ability to adapt and maintain focus in fast paced, quickly changing or stressful situations.
2. Ability to read and interpret a variety of documents including, but not limited to policies, operating instructions, white papers, regulations, rules and laws.
3. Ability to ask for money, explain insurance benefits as it pertains to each departments job functions.

ESSENTIAL SENSORY REQUIREMENTS

1. Able to see for the purpose of reading information received in formats including but not limited to paper, computer, reports, bulletins, updates, manuals.
2. Able to hear for work-related purposes.
3. Ability to communicate receptively and expressively both written and spoken.
4. Ability to maintain self-control.
5. Ability to direct phone calls or requests effectively if answer is not known.

INTERPERSONAL SKILLS

1. Ability to interact with co-workers, hospital staff, administration, patients, physicians, the public and all internal and external customers in a professional and effective, courteous and tactful manner, at all times, physically, verbally and in all written and electronic communication.
2. Required to remain calm when adversity is encountered.
3. Open, honest, and tactful communication skills.
4. Ability to work as a team member in all activities.
5. Positive, cooperative and motivated attitude.