A Medical Claims Processor or Representative reviews and processes medical insurance claims and determines whether an insurance policy will cover a medical procedure. Gathers information from policy holders and organizes insurance files; may process checks with payments to policy holders when a medical claim is approved.
8 Hr (9:00:00 AM - 5:30:00 PM) Rush offers exceptional rewards and benefits learn more at our Rush benefits page (https://www.rush.edu/rush-careers/employee-benefits).
Pay Range:
$18.87 - $26.66 per hour Rush salaries are determined by many factors including, but not limited to, education, job-related experience and skills, as well as internal equity and industry specific market data. The pay range for each role reflects Rush's anticipated wage or salary reasonably expected to be offered for the position. Offers may vary depending on the circumstances of each case.
Summary:
Rush University Medical Center is seeking a Prior Authorization Specialist I to support patients, providers, and the revenue cycle by obtaining insurance authorizations and ensuring services meet payer requirements before care is delivered. In this role, you will verify insurance coverage, secure referrals and prior authorizations, gather required clinical and demographic information, and collaborate with patients, providers, and insurance carriers to support timely access to care. You will also assist with registration and insurance review activities that help ensure accurate reimbursement and a positive patient experience. This position is ideal for a detail-oriented, customer-focused professional who enjoys problem-solving and thrives in a fast-paced healthcare environment. Experience in healthcare, insurance, patient access, registration, financial clearance, or customer service is preferred but not required. Join Rush and become part of a mission-driven team dedicated to improving the patient experience and supporting high-quality healthcare delivery.
Responsibilities:
Reviews, collects and properly records demographic and insurance information required to properly address the customers' authorization requirements and identify any financial issues. Verifies patient's eligibility from resources provided by third party payers and portals and other on lines services. Collects and analyzes demographic, insurance and other information from the patient, guarantor and all other sources to accurately obtain authorization for scheduled procedure. Assembles information concerning the patient's clinical background and clinical information that is required for the payer to issue a referral or an authorization. Per referral guidelines, provide appropriate clinical information to the payer. Contact review organizations and insurance companies to ensure prior approval requirements are met. Present necessary medical information such as history, diagnosis, CPT codes and clinical notes. Provide specific medical information to financial services to maximize reimbursement to the hospital and professional service providers. Performs registration functions consistent with Federal, State and Local regulatory agencies and payer requirements, and organizational policies and procedures, including HIPAA privacy and security Regulations, as well as JACHO. Consistently maintains authorization accuracy rates at and or above department standard in performance of registration and authorization duties. Customers. Able to find resolution within the phone interaction satisfactory to the caller and/or having the knowledge when to escalate to their supervisor. Interacts and collaborates with numerous departments to resolve issues while also analyzing necessary information that will ensure hospital reimbursement. Appropriately informs the patients of hospital policies that govern the revenue cycle, the amount owed by the patients and explains hospital payment policy. Offers option of Financial Counselors to assist in acceptable resolution of estimated patient balance. Receives and properly responds to, or directs telephone and electronic inquiries from patients, payers, physicians and their staff, internal department and other persons and entities. Ability to exercise good customer service skills when communicating with both our patients as well as our internal customers. Able to find resolution within the phone interaction satisfactory to the caller and/or having the knowledge when to escalate to their supervisor. Performs other duties as assigned for the operational effectiveness and success of the department. Interacts and collaborates with numerous departments to resolve issues while also analyzing necessary information that will ensure hospital reimbursement. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Rush University Medical Center's Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical, and professional behavior. Guards to assure that HIPAA confidential medical information is protected Attends regular EPIC training sessions or other sessions conducted for the benefit of associates involved in the Financial Counseling functions. Other duties as needed and assigned by the supervisor/manager.
Required Job Qualifications:
High school graduate or equivalent. 0-1 year of experience Must have a basic understanding of the core Microsoft suite offerings (Word, PowerPoint, Excel). Excellent communication and outstanding customer service and listing skills. Basic keyboarding skills Ability to analyze and interpret data Critical thinking, sound judgment and strong problem-solving skills essential Team oriented, open minded, flexible, and willing to learn Strong attention to detail and accuracy required Ability to prioritize and function effectively, efficiently, and accurately in a multi-tasking complex, fast paced and challenging department. Ability to follow oral and written instructions and established procedures Ability to function independently and manage own time and work tasks Ability to maintain accuracy and consistency Ability to maintain confidentiality
Preferred Job Qualifications:
Associates Degree in Accounting or Business Administration Experience within a hospital or clinic environment, a health insurance company, managed care organization or other health care financial service setting, performing medical claims processing, financial counseling, financial clearance, accounting, or customer service. Knowledge of insurance and governmental programs, regulations, and billing processes e.g., Medicare, Medicaid, Social Security Disability, Champus, Supplemental Security Income Disability, etc., managed care contracts and coordination of benefits is highly desired. Working knowledge of medical terminology and anatomy and physiology is preferable. Rush is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics. Position Prior Authorization Specialist 1
