Prior Authorization Specialist I

Responsible for screening prior-authorization and coordination of specialized services requests in the medical care management program. Adheres to policies and procedures in order to comply with performance and compliance standards and to ensure cost effective and appropriate healthcare delivery.

Requirements

• Prioritize incoming Prior Authorization requests
• Process incoming requests, including authorizing specified services
• Refer authorization requests that require clinical judgment to Prior Authorization Clinician, Manager, or Medical Director
• Meet or exceed position metrics and Turn-Around Timeframes while maintaining a full caseload
• Support Prior Authorization Clinicians
• Answer ACD line calls
• Identify and inform callers of network providers, services, and available member benefits
• Informs provider of decision per department procedure
• Coordinates resolution of escalated member or provider inquiries as related to Prior Authorization
• Works with members, providers and key departments to promote an understanding of Prior Authorization requirements and processes
• Maintains general understanding of applicable sections of member handbooks, and evidence of coverage
• Monitors accounts routed to registration and prior authorization work queues
• Maintains knowledge of and complies with insurance companies' requirements for obtaining prior authorizations/referrals
• Acts as subject matter experts in navigating both the BMC and payer policies to get the appropriate approvals
• Uses appropriate strategies to underscore the most efficient process to obtaining insurance verification, authorizations and referrals
• Obtains and clearly documents all referral/prior authorizations for scheduled services prior to admission within the Epic environment
• Collaborates with primary care practices, specialty practices, referring physicians, primary care physicians, insurance carriers, patients and any other parties to ensure that required managed care referrals and prior authorizations for specified specialty visits and other services are obtained and appropriately recorded in the relevant practice management systems for patient appointments/visits prior to scheduled patient visits or retro-actively if not in place at the time of the appointment/visit
• Ensure that approval numbers are appropriately linked to the relevant patient appointment/visit
• Collaborates with patients, providers, and departments to obtain all necessary information and payer permissions prior to patients' scheduled services
• Liaison between physician and payer for peer to peer review when needed
• Escalates accounts that have been denied or will not be financially cleared as outlined by department policy
• Interview patients, families or referring physicians via telephone in advance of the patient's appointment/visit whenever possible, to obtain all necessary information, including but not limited to, financial and demographic information required for reimbursement and compliance for services rendered
• Ensure that all updated demographic and insurance information is accurately recorded in the appropriate registration systems for primary, secondary and tertiary insurances
• Review all registration and insurance information in systems and reconcile with information available from insurance carriers. For any insurance updates, utilize any available resources to validate the updated insurance information, insurance plan eligibility, primary care physician, subscriber information, employer information and appointment/visit information.
• Contact patients as necessary if clarifications or other follow-up is required, and at all times maintain sensitivity and a clear customer friendly approach.
• For self-pay patients or patients with unresolved insurance, and for financial counseling, refer patients Patient Financial Counseling
• Maintains confidentiality of patient's financial and medical records; adheres to the State and Federal laws regulating collection in healthcare; adheres to enterprise and other regulatory confidentiality policies; and advises management of any potential compliance issues immediately.

Benefits

• Medical
• Dental
• Vision
• Pharmacy
• Flexible Spending Accounts
• 403(b) savings matches
• Earned time cash out
• Paid time off
• Career advancement opportunities
• Resources to support employee and family wellbeing