Department Patient Access Exempt Immediate Patient Access Manager Non-Exempt Supervisor Supervisor next Chief of Clinic Operations Workweek Up to 40 hrs week in line

POSITION SUMMARY

Prior Authorization Specialist is a pivotal role that supports the hospital's mission of providing high- quality, patient-centered care through data collection and analysis, critical thinking, collaboration, and operational excellence. Prior Authorization Specialist reviews all submitted orders (electronically and manual) and performs prior authorizations as required by payor source, including procurement of needed documentation by collaborating with physician's office and insurance companies. Works as a patient advocate and functions as a liaison between the patient, staff and payer to avoid care delays. Tracks, documents, and monitors authorizations. Implements check and balance systems to ensure timely compliance. Processes complete prescription claims including proper adjudication/reconciliation, insurance verification, and prior authorization. Continued employment and raises in this position are dependent upon Central Montana Medical Center's fiscal viability and:  Actions and communications that contribute to a team concept and create a positive environment for all customers  Acceptable performance of essential and all job duties  Acceptable attendance record  Accountability for safety to self, patients, visitors and all customers, and care of equipment and building  Adherence to departmental and facility policies and procedures, education requirements, compliance monitoring and reporting, and CMMC Code of Conduct  Accountability for the consequences of own actions  Physical and emotional ability to perform essential functions  Acceptable background investigation results if required for position Minimum Education, Experience, Licensure, Certification required:  High School Diploma or Equivalent  Minimum of 2 years of experience in patient access, or a similar role within a healthcare setting.  Strong understanding of healthcare operations, insurance processes, and government programs.  Experience with ICD-10 coding, outpatient admission procedures and benefit authorization preferred.  Experience with Commercial, Medicare/Medicaid, COBRA and HMO/PPO insurance products  PACS Certification preferred - Must be able to obtain within 6 months of hire date

ESSENTIAL FUNCTIONS/DUTIES

(Must be able to perform with or without accommodation) 1 Identifies and initiates precertification/authorization requirements for individual payers and communicates with payer sources in a timely manner to obtain necessary pre- certification/authorization. 2 Validate insurance entries using software, commercial web sites, or calling insurance company and analyze electronic/verbal responses ensuring appropriate set-ups.

SPECIALIST 3

Ensures Medicaid Passport and other authorizations for referrals required by insurance carriers are obtained and entered onto specifically approved encounters within the revenue cycle system. 4 Reviews and analyzes AccuReg edits, complete corrections in accordance with AccuReg procedure. 5 Ensure all work queues are completed and maintained within guidelines and provide appropriate hand-off information to others. 6 Understands insurance/payer policy language, benefits and authorization requirements upon admission, for concurrent review, and for discharge. 7 Coordinates Peer to Peer reviews. Submits letters of medical necessity and follows up on payer denial outcomes. 8 Conducts follow-up calls, as necessary, to third party payers to complete authorization process validating that all days are authorized. 9 Facilitates retro-authorization process with payers. Communicates outcome with patient, physician, Patient Financial Services and other key departments. 10 Responsible for coordinating resolution of varied problem situations and performing necessary investigation and research as it relates to the authorization process to resolve pre-certification/authorization problems. 11 Works closely with Payer Relations coordinating needed pre-certification/ authorizations for in-network and out of network services. 12 Maintains reference manuals that outline the individual payer requirements as it relates to precertification and authorization needs while also being responsible for the integrity and accuracy of the payer data. 13 Responsible for the orientation and education of physicians and nursing staff, who rely on the pre-certification process. 14 Works with Coding Resources validating correct and billable CPT code, writes process with critical elements for new procedures and maintains pre-certification instruction manual. 15 Reviews, updates and standardizes forms and processes as needed. 16 Initiates workflow for new procedures/service lines. Collaboration and Problem Resolution 17 Collaborate with department leaders to identify areas for process enhancement. 18 Generate and analyze reports related to patient access metrics, providing insights and recommendations.

Special Projects and Continuous Improvement:

19 Participate in objectives to drive Pre-access improvements. 20 Maintain a thorough understanding of health insurance and government programs to support patient access operations. 21 Perform other diverse duties as requested or required.

SPECIALIST

Knowledge, Skills, Abilities:

Excellent organizational and time management skills. Strong interpersonal communication skills. Ability to work independently and collaboratively in a team environment. Advanced computer skills , including a high degree of proficiency in Microsoft Word, Excel, Teams and Outlook.

OCCUPATIONAL EXPOSURE

for this position: Category I Direct contact with blood or other bodily fluid to which universal precautions apply. Category II Activity performed without blood/bodily fluids exposure, but exposure may occur in emergency. Category III Task/activity does not ordinarily entail predictable exposure to blood/bodily fluids.

OTHER EXPOSURE

for this position: Radiation Noise Other (Specify) Extended periods in front of a

PC. PHYSICAL DEMANDS

: (Essential functions strength rating for position - see Job Analysis) Sedentary Exert up to 10# occasionally or negligible force frequently Light Exert up to 20# occasionally, < 10# frequently or negligible force constantly Medium Exert up to 50# occasionally, up to 25# or up to 10# constantly Heavy Exert up to 100# occasionally, up to 50# frequently or up to 20# constantly Very Heavy Exert > 100# occasionally, > 50# frequently or > 20# constantly