Authorization Specialist- HVI, Children's Hospital

UPMC•Pittsburgh, PA

1d•Onsite

About The Position

University of Pittsburgh Physicians is hiring a full-time Authorization Specialist for the Heart and Vascular Institute at Children's Hospital of Pittsburgh. This position is on-site Monday through Friday, 8:00 a.m. to 4:30 p.m. Previous experience in authorization and scheduling is required. The Authorization Specialist performs authorization activities for inpatient, outpatient, and emergency department patients, along with denial management and other revenue functions. The role includes pre-authorizations, notifications, edits, and denials, and requires consistent adherence to high performance standards and UPMC's philosophy and core values. The specialist reviews medical records and applies payor criteria or relevant state laws and regulations to support authorization decisions and medical-necessity determinations. The role also involves accurate coding, timely submission of authorization and referral requests, resolution of authorization edits, and collaboration with internal and external contacts to coordinate services and support process compliance.

Requirements

Previous experience in authorization and scheduling is required.
High school diploma or equivalent and 2 years of work experience in a medical environment, such as a hospital, doctor's office, or ambulatory clinic; or an associate degree and 1 year of experience in a medical environment.
Completion of a medical terminology course or equivalent.
Knowledge and interpretation of medical terminology, ICD-9, and CPT codes.
Proficiency in Microsoft Office applications.
Excellent communication and interpersonal skills.
Ability to analyze data and use independent judgment.
Must obtain and maintain Act 31 Child Abuse Reporting, Act 33, Act 34, and Act 73 FBI clearances, including renewals.

Nice To Haves

Bachelor's degree (B.A.).
Understanding of authorization processes, insurance guidelines, third-party payors, and reimbursement practices.
Experience using a web-based computerized system.

Responsibilities

Review and interpret medical record documentation, including patient history, diagnoses, and prior treatment plans, to pre-authorize insurance-plan procedures.
Use payor-approved criteria or state laws and regulations to assess medical necessity or clinical appropriateness for inpatient admissions, outpatient facility and office services, durable medical equipment, and drugs.
Ensure accurate coding of diagnoses, procedures, and services using ICD-9-CM, CPT, and HCPCS Level II.
Provide referral, pre-notification, and authorization services in a timely manner to prevent treatment delays and reduce providers' nonclinical administrative work.
Submit relevant demographic and supporting clinical information to payors to request approval for services.
Maintain compliance with departmental quality standards and productivity measures.
Collaborate with internal and external contacts, including Physician Services, the Hospital Division, UPMC teams, and payors, to support customer satisfaction, process compliance, coordinated work, and avoidance of negative financial impact.
Use UPMC system and insurance payor or contracted provider websites to perform prior authorization, edit, and denial services.
Use authorization resources and other applicable reference materials to obtain accurate prior authorization.
Resolve basic authorization edits retrospectively to support timely claim filing and prevent payor rejections or denials.