Prior Authorization Specialist

Litchfield, MN, United StatesYesterday

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Skills

clinical documentationcompliancecustomer servicedata entryehremrexcelgoogle workspacehipaaicd-10medical recordsmedical terminologymicrosoft officemicrosoft teamsmicrosoft wordoutlookpatient schedulingprior authorizationregulatory complianceword processing

About the role

Position Overview

The Prior Authorization Specialist coordinates medication prior authorizations and patient assistance programs to help ensure patients have access to prescribed medications. Responsibilities include working with insurance companies, pharmacies, providers, and medication assistance programs to obtain approvals, identify financial assistance opportunities, and support timely access to necessary medications. The position we are looking to hire is a 0.5 - 0.7 FTE (40 - 56 hours bi-weekly).

Position Summary

The Prior Authorization Specialist is responsible for obtaining authorizations for service from various insurance carriers. The Prior Authorization Specialist will complete necessary third-party prior authorization through telecommunications and computer information systems. The Prior Authorization Specialist will complete reviews of denials in conjunction with the Credit/Collection Specialists.

Essential Job Functions

Job functions are those tasks, duties, and responsibilities that comprise the means of accomplishing the job’s purpose and objectives. Job functions are critical or fundamental to the performance of the job. They are the major functions for which the person in the job is held accountable.

• Review order for services that require prior authorization.
• Review and complete insurance eligibility checking to determine appropriate third party payor insurance prior authorization requirements.
• Review clinical data matching the ICD-10-CM codes and CPT codes against medical policies to determine medical necessity and follow established procedures for authorizing request or referring request for further review.
• Coordinates authorizations for procedures and testing required by providers for their managed care patients.
• Obtain clinical documentation to support the medical necessity and prior authorization requirements.
• Notify parties with precertification numbers as needed and file completed precertification request per established policy.
• Communicates the approval or denial of prior authorization requests with the patient and ordering provider’s clinic.
• Accurately enter required prior authorization/reference information into computer database
• Assist departments or patients when requesting benefit information or insurance coverage.
• Prepares all forms required by third party payors for treatment authorization requests.
• Submits prior authorization documents to third party payors in a timely and efficient manner.
• Completes denial review with Patient Financial Services when authorization is not completed or incorrect.
• Completes continuing education on third party prior authorization requirements by accessing their websites and on-line learning modules.

Note: This job description does not state or imply that the above are the only duties and responsibilities assigned to this position. Employees holding this position may be directed to perform job-related tasks other than those specifically presented in this job description.

Qualifications

Minimum Qualifications

• Associate's degree (A. A.) or equivalent from two-year college or technical school
• Six months to one year related experience and/or training
• Or approved equivalent combination of education and experience.

Knowledge, Skills & Abilities (KSAs)

• Basic computer and word processing skills
• Ability to work with multiple phone lines
• Basic medical terminology and patient scheduling
• Excellent communication and customer service skills
• Skilled at incorporating AIDET into professional practice.
• Knowledge of role in patient confidentiality and protecting patient information from unauthorized access, use, or disclosure as defined by HIPAA.
• Ability to respond quickly and decisively to emergency situations and participate in shelter-in-place and disaster response protocols.
• Ability to work with interdisciplinary teams, communicating effectively with patients, families, and healthcare providers.
• Data entry accuracy

Preferred Qualifications

• Familiarity with EPIC electronic medical record system.
• Previous experience in a prior authorization role in a healthcare system.
• Previous pharmacy technician experience is welcomed.

Computer Skills

Proficiency in Microsoft Office Suite (Word, Excel, Outlook), secure messaging applications, and collaborative tools (e.g.) Microsoft Teams, Google Workspace. Proficient with Paycom and other Information Systems applicable to position i.e. Internet software; Healthland Scheduling/EHR, maintains accurate patient records, and effectively utilize electronic health record (EHR) systems i.e. EPIC.

Reasoning & Critical Thinking

Apply logical problem-solving and decision-making skills in complex situations. Make sound decisions in real time, often under pressure (early warning signs, inconsistencies, potential complications) using critical thinking. Analyze data and scenarios to identify patterns, inconsistencies, and opportunities. Evaluate multiple approaches and propose innovative solutions with sound judgement. Able to work independently with limited supervision.

Language & Communication Skills

Adapt tone, style, and messaging for diverse audiences and contexts. Ability to write high-quality drafts, proposals, reports, and presentations. Ability to effectively present information in one-on-one meetings as well as small and larger groups, i.e. employees, customers, vendors, community organizations, etc. Collaborate across departments to relay messages and coordinate care smoothly.

Mathematics & Analytical Abilities

Ability to accurately perform basic mathematical calculations in all units of measure using whole numbers, common fractions, percentages, ratios, and proportions to practical situations and in analysis of quality assurance data. Ability to understand bar graphs and other visual representations of data. Accurately record and interpret clinical measurements. Use EMR systems and care documentation tools to analyze data trends and support treatment.

Standards of Employment

• Understand and adhere to MMHC’s compliance standards as outlined in MMHC’s Compliance Program.
• Attend all mandatory education programs and demonstrate proficiency related to general safety and regulatory compliance.
• Attend all department-specific training and demonstrate proficiency related to safety and job-related hazards.
• Understand and follow MHC procedures for exposure control / blood borne and airborne pathogens.
• Comply with all relevant MMHC policies, procedures, guidelines, and all other regulatory standards and requirements.
• Attire is neat, clean, and appropriate for the work environment and according to MMHC policy.
• Wear proper identification while on duty.
• Maintain confidentiality of all MMHC and patient information at all times.
• Report to work on time and maintain defined standards for attendance.
• Attend mandatory meetings.
• Able to perform essential job duties that meet job performance expectations and organizational standards while upholding MMHC mission and values.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand; walk; sit; use hands to finger, handle, or feel and reach with hands and arms. The employee is occasionally required to climb or balance; stoop, kneel, crouch, or crawl and taste or smell. The employee must frequently lift and/or move (push/pull) up to 25 pounds and occasionally lift and/or move up to 35 pounds. Lifting/and or moving of more than 35 pounds shall require the use of an assistive device or team member assist. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus. Ability to meet physical demands of rural hospital/clinic work, including during emergency situations and/or disaster protocols.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is occasionally exposed to moving mechanical parts; needles or sharps; the challenges of variable hours, shifting resources, and work situations inherent in CAH/rural settings; Hazards and/or Biohazard Medications; fumes or airborne particles; toxic or caustic chemicals; outside weather conditions; risk of electric shock and radiation; bloodborne pathogens and exposed to latex. The noise level in the work environment is usually moderate.