Prior Authorization Specialist

Description:

Description The Prior Authorization Specialist is responsible for servicing the needs of patients, providers, and the Health Plans representatives, by effectively handling referrals from providers to facilitate the clinical review, issue authorizations and coordination of referrals services utilizing pre-approved screening criteria in compliance with contracted Client's requirements and adopted clinical guidelines. Handles the more complex requests for treatment and authorization requests. Conducts searches on authorization requests to handle complex Provider inquiries. Job Duties Obtain prior authorizations for diagnostic imaging, prescription medications, Home Health, and Durable Medical Equipment. Receives referral requests from providers and Health Plans representatives. Assist in processing medical services request. Completes clerical duties related to the processing of Authorization Requests and Provider Referrals. Verifies member's eligibility and benefits with subsequent notification to designated staff of eligibility issues. Inputs all requests for services received via fax or phone into the system accurately for electronically generated authorization and tracking. Provides services authorizations to providers per UM Departmental Policy and Procedures and specific contracted Client's process on a timely manner. Requests submission of appropriate medical records according to established criteria for requested service(s) in accordance with the corresponding Policy and Procedure. Notifies required parties within the appropriate timeframe for routine and urgent requests for services. Research member history for duplications and consideration of authorization limits. Verifies fax numbers and system updates. Communicates with requesting provider for any identified need to clarify a request for an authorization, such as CPT codes, ICD10, requested timeframes and member's demographics. Provides effective departmental communication with both internal and external sources. Forwards Authorizations to appropriate department staff in terms of eligibility and other coverage, pricing, and benefit issues. Scans, attaches, reviews and effectively works with electronic images as part of the authorization process. Including recording the required information from attachments into the authorization fields. Collaborates with Supervisor and Insurance companies to resolve complex authorization issues. Appropriately forwards all referral requests to the next level of clinical review as applicable and after verifying for completeness and appropriateness. Coordinates approved outpatient surgical procedures in specialist's office and/or outpatient surgical facilities with health plan's authorization department when applicable. Coordinates approved services with Home Health and Durable Medical Equipment Providers, Nurse Care Managers, Plan discharge Planners and Plan Members as delegated or required by Plan. Is resource person for PCP to refer to network specialist(s). Maintains appropriate logs, records, and reports as established. Documents and communicates areas of concern to supervisor. Identifies providers who show an educational need to follow national, state and plan requirements. Adheres to company HIPAA policies and procedures. Identifying, maintaining and protecting sensitive HIPAA information (PHI) and following procedures to ensure the security of such information. Perform other duties as assigned.

Requirements:

Education High school diploma or general education degree (GED); Medical coding or authorization education/training preferred.

Experience & Skills Required Required:

computer literacy and advanced data entry capacity (++45 wpm)

Required:

3 - 5 years' experience in a medical office setting Experience processing/managing referrals or authorization requests in a Utilization Management department for 2 years, demonstrating production and accuracy well above the minimum required goals, or an equivalent combination of education and experience, which would provide the required knowledge, skills and abilities may also be qualifying. MMR, TB and Flu