Prior Authorization Specialist- CPKH Pain Mgmt Center

Position Summary:


Under the supervision of department leadership, this position is responsible for ensuring accurate and timely prior-authorization of procedures, medications, and other insurance verifications as assigned. This responsibility includes working to reverse denials, processing appeals and coordinating peer-to-peer discussions. Secondary focus of this position includes departmental hospital billing and patient Liaison responsibilities. This position works with providers, nurses, insurance reps, and other financial advocates to resolve issues that arise during the prior authorizations process.

Qualifications:


EDUCATIONAL REQUIREMENTS
H.S. Diploma/GED

ADDITIONAL REQUIREMENTS

• Use of usual and customary equipment used to perform essential functions of the position.
• Work may occasionally require travel to other Carle Health facilities/hospitals.
• Required to drive your own vehicle for business purposes.

Essential Functions:

• Serves as the department expert for prior authorizations. * Assists department leadership to optimize and implement current prior authorization workflow, procedures, documentation, and communication. * Stays informed and researches new information as needed regarding LCDs, NCDs, formulary lists, and specific insurance criteria necessary to obtain prior authorization and reimbursement for services provided within pain management specialty. * Educates and communicates with providers and clinical staff regarding the above information to help facilitate optimum patient treatment plans, documentation, and payment of services. * Ability to navigate and maneuver through multiple web sites* Keeps current, organized, and detailed information needed to complete this role in one location either on paper or in an electronic file. * Collaborates with clinical integration and pain center team to optimize and standardize EMR documentation identifying prior authorization needs, medical necessity detail, and other criteria surrounding such authorizations.* Seeks assistance when required for clinical expertise with insurance verification or other patient/provider needs.* Serves as primary resource to patients regarding prior authorization process.* Demonstrates ability to complete work with a high level of detail and accuracy.
• Identifies, processes, and communicates the completion of all department patient accounts/orders that require insurance verification, prior authorization, and/or pre-certification in a timely manner. This includes the coordination, processing, and resolution of denials, appeals, and peer-to peer reviews.* Receives requests for prior authorizations.* Validates patient coverage, benefits and eligibility.* Demonstrates ability to work efficiently, independently, prioritizing authorizations based on patient needs and department procedure schedules. * Initiates Prior Authorization request to insurance carriers and/or primary care physicians in accordance with specific payer processes (website, fax, phone).* Ensures accurate ICD, CPT codes and related medical records are submitted in the authorization request.* Creates detailed documentation and maintains/stores the authorization *paper trail'.* Follows-up on and completes prior authorization requests.* Informs providers and their clinical staff when issues arise relating to obtaining prior authorization.* Communicates with patients regarding authorization status. * Demonstrates a professional image in dealing with team members, providers, patients, families and payors.* Verifies and accurately documents third party responses to authorizations in the EMR.* Follows up on delayed or denied authorization requests, gathers additional clinical/coding information, as necessary, submits appeals or escalates appropriately for resolution while meeting specified deadlines as required by said third party.
• Serves as the departmental billing liaison for patients and UPH CBO* Reconciles daily patient charges for accuracy.* Assists patients to estimate costs prior to patient appointments according to department guidelines including insurance portions and self-pay estimates.* Works to resolve claims/denials related to the prior authorization.* Takes ownership of the patient account work queue (requires working with providers and CBO patient account representatives and coding team to correct charges and/or billing issues). Completes these accounts in a timely manner.* Completes other department duties as assigned by immediate supervisor.