INTERNAL

\nPATIENT FINANCE\nFT, Day Shift\nReq # 3158\nHigh School/GED\n

Title:

PFS Prior Authorization Specialist\n

Reporting Relationship:

Patient Financial Services Manager\nPosition Summary\nThe position is responsible for overseeing the daily operations of the prior authorization team, ensuring timely and accurate insurance pre-approvals for all medical services, procedures, and treatments, This role acts as a subject matter expert, managing complex cases, training staff, and coordinating communication between physicians, insurance companies, and patients to minimize delays in care and financial risk to the hospital.\n

Essential Job Functions:

\nLead, mentor, and train a team of prior authorization specialists, ensuring proper workload distribution and adherence to policies and procedures.\nOversee the prior authorization workflow to ensure all requests are processed accurately and within defined turnaround times.\nServe as the primary point of contact and escalation for complex authorization issues, denials, and coverage conflicts, using independent judgement for resolution.\nEnsure accurate and complete collection of patient demographic, insurance, and clinical information.\nVerify patient insurance eligibility and benefits for specific procedures or medications. Communicate coverage issues to the ordering provider.\nSubmit authorization requests to insurance carriers via portals or phone, leveraging expertise in CPT and ICD-10 coding guidelines.\nManage an effective denial management process. Oversee the appeals process for denied claims, gathering additional medical necessity documentation as needed to overturn denials.\nAct as a liaison between the prior authorization team, physicians, clinical staff, patient financial services, and financial counseling and multiple other departments to ensure seamless communication, process alignment, and compliance with payer requirements.\nReview patient medical records and physician notes to ensure all clinical documentation supports the medical necessity criteria required by the insurance payers. Gather missing information from clinical staff to build a complete case for approval.\nHelp patients navigate and apply for copay assistance or other patient assistance to make treatment more affordable.\nIdentify and report trends in denials or payment variances, suggesting process improvement to management.\nEnsure all activities are in compliance with managed care contracts, insurance policies, and federal and state regulations (e.g., HIPAA).\nMaintain accurate records in the EHR systems.

Other Job Functions:

\nEnhances professional development by taking steps to remain knowledgeable of industry standards, and attending meetings and seminars as assigned.\nActively participates in BBGH Performance Improvement activities.\nMaintain all documentation and records in accordance with department procedures, federal and state regulations.\nAttends a minimum of 90% of mandatory staff meetings. Performs related business office responsibilities as assigned by PFS Manager.\nContributes to the prevention of infectious disease among employees and patients by adhering to infection control policies and procedures.\nContributes to adequate staffing of department by reporting to work at scheduled time.\nContributes to effective guest relations by assisting patients, visitors and physicians to resolve expressed concerns and demonstrating a welcoming and helpful attitude.\nConserves hospital resources by using equipment and supplies as needed to perform job duties.\nKeeps information confidential by adhering to the terms of personnel policy concerning confidentiality.\nMaintains a clean and calm environment.\nCompletes all required paperwork/computer entry for each patient needed.\nFollow the Standards of Behavior.\nUtilize TeamSTEPPS tools.\nParticipate in Patient Experience.\nRegular Attendance.\nProvides back-up for Communication Clerk during vacancies and absences.\nPerforms other related duties as assigned or requested.\n

Job Qualifications:

Age Requirement Required:

Must be 19 years or older Education\n

Required:

High School Diploma or GED equivalent\nExperience/Qualifications\n

Required:

\nComputer Skills/Keyboarding.\nKnowledge of health insurance processes, medical terminology and payer-specific guidelines.\nIntermediate knowledge of CPT and ICD-10 coding guidelines.\nProficiency in using EHR systems and various payer portals\n

Preferred:

\nPrevious experience in a hospital, clinic, or medical office setting with a strong focus on prior authorization and insurance verification.\n1 year of experience in prior authorization position. Knowledge of computer including navigating the internet in order to look up eligibility status using various websites.\nExperience in submitting prior authorization request via payer portal, fax or phone. General knowledge of Medicare, Medicaid, and commercial insurance companies.\nGeneral knowledge of MVA insurance, 3rd party liability, and workmen comp insurance.\nUnderstanding of Microsoft Excel and Outlook. Licenses/Certifications\n

Required:

None Preferred:

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