POSITION SUMMARY
The Prior Authorization Specialist plays a critical role in an effective prior authorization program. This position ensures patients receive timely and appropriate medical services by securing insurance approvals for procedures, treatments, and hospital admissions. This position requires a deep understanding of insurance guidelines, medical terminology, and healthcare workflows to facilitate efficient and accurate authorization processes.
ESSENTIAL JOB DUTIES & RESPONSIBLITIES
- Contact patient insurance companies to verify patient insurance and benefits for scheduled services and hospital admissions
- Obtain, process and document prior authorizations in the electronic medical record (EMR) including authorization numbers, CPT codes, diagnosis, and approval dates
- Submit supporting medical records and necessary information to payer authorization representatives via fax, phone, or online portals
- Stay up to date with payer trends for prior authorizations
- Prioritize workload to ensure urgent cases are handled in a timely manner
- Ensure timely and accurate insurance authorizations are in place prior to services being rendered
- Maintain accurate payer website information and logins
- Communicate regularly with other departments and educate staff on authorization needs
- Develop and maintain working relationships with external agencies and specialty providers
- Explain notice of non-coverage or offers to re-schedule elective tests and procedures, when patient pre-authorization is not obtained; notify patient and physician of outcome
- Ensure urgent/emergent cases are worked within one business day & elective cases prior to date of service
- Serve as liaison to hospital departments, physician offices, and patients for authorization or financial responsibility questions
- Facilitate authorization process with offices and providers
- Obtain clinical information from physician offices and HIM for CPT/ICD-10 codes
- Monitor prior authorization outcomes and maintain awareness of approvals and any denials resulting from inaccurate or incomplete information, communicating with Patient Accounting and the Revenue Cycle Action Team as needed.
- Connect patients/guarantors to Financial Counselor for estimates
- Maintain professional growth through seminars, workshops, and affiliations
- Participate in meetings, committees, and department projects as needed
Hours: Minimum 20 hours/week; Monday-Friday 8:00am - 4:30pm
Keyword: Financial Counselor
Required Experience:
Education, Experience:
• High school diploma or equivalent
• Experience in insurance verification or prior authorizations
• Familiarity with health insurance plans, ICD/CPT coding, and EMR systems
• Strong organizational and customer service skills
• Proficient in computer navigation, word processing, and email
Certificates, Licensure, Registrations:
• None
GENERAL REQUIREMENTS
• Basic math and reading comprehension
• Ability to use computer systems and write reports
• Adaptability and problem-solving skills
• Strong interpersonal and communication abilities
EQUIPMENT, TOOLS, MATERIALS
• Knowledge of relevant computer hardware and software
Benefits:
Standard full-time benefits: Benefits go into effect on the 1st of the month following 30 days of employment. Include but not limited to:
- Health Insurance: PPO and H.S.A. option; PCH pays a portion of premiums
- Dental & Vision Insurance
- Life Insurance: Life and Accidental Death and Dismemberment Plan at no cost to the employee; opportunity to purchase additional coverage also available
- Paid Time Off (PTO): Accrue hours based on a percentage rate (set by years of service) multiplied by the number of hours worked in a pay period
- 403(b) Retirement: The hospital will match employee contributions for their retirement, up to a percentage employee gross wage
- Short Term Disability, Long Term Disability, Critical Illness, Accident Policies
- Medical and Dependent Care Savings Accounts
- Group Incentive Plan (GIP): The hospital sets facility wide goals for our annual fiscal year. Depending on how many of those goals we meet at the end of the fiscal year that determines the amount of bonus employees receive.
This institution is an EEO/AA Employer and Provider - Protected Veterans and Individuals with Disabilities.
From: Pender Community Health