Home Healthcare Pre-Authorization

Human Touch Home Health Care•Washington, DC

3d•Onsite

About The Position

Human Touch is seeking an experienced Home Health Prior Authorization Specialist to manage the authorization process for patients receiving home health services. The Prior Authorization Specialist will be responsible for obtaining initial and continued authorizations from insurance companies and managed care organizations, verifying patient eligibility and benefits, submitting required clinical documentation, tracking authorization status and expiration dates, and communicating with payers, clinicians, referral sources, and internal staff. The ideal candidate will have experience working with home health insurance authorizations, Medicaid, Medicare Advantage, managed care organizations, and payer portals. Strong attention to detail, organization, follow-up, and knowledge of home health documentation requirements are essential.

Requirements

High school diploma or GED required.
2+ years of experience in medical insurance authorization, utilization management, referral coordination, or a related healthcare administrative role.
Home health authorization experience strongly preferred.
Experience working with Medicare Advantage, Medicaid, commercial insurance, and/or managed care organizations preferred.
Knowledge of home health services and authorization requirements.
Experience using insurance payer portals and electronic medical record systems.
Strong computer and data-entry skills.
Excellent verbal and written communication skills.
Strong organizational skills and attention to detail.
Ability to manage multiple authorization requests and deadlines simultaneously.
Ability to work independently while maintaining effective communication with the clinical and administrative teams.

Nice To Haves

Home health authorization
Home health intake
Utilization management
Insurance verification
Medicaid authorization
Medicare Advantage authorization
Managed care organizations
OASIS documentation
Plan of Care / 485 documentation
Therapy authorization
Payer portals
Referral coordination
Clinical documentation review

Responsibilities

Obtain prior authorizations for home health services, including skilled nursing, physical therapy, occupational therapy, speech therapy, and other covered services as applicable.
Review referrals and patient information to determine authorization requirements.
Verify patient insurance eligibility, benefits, coverage, and authorization requirements.
Submit initial authorization requests to insurance companies and managed care organizations.
Submit requests for continued services and additional visits when medically necessary.
Review authorization requirements and ensure all required clinical documentation is submitted accurately and timely.
Coordinate with clinical staff to obtain OASIS assessments, plans of care, therapy evaluations, physician orders, progress notes, and other required documentation.
Track authorization requests from submission through approval, denial, or pending status.
Monitor authorization expiration dates and proactively initiate renewal requests to prevent gaps in patient services.
Maintain accurate authorization records in the agency's electronic medical record and/or authorization tracking system.
Document authorization numbers, approved disciplines, approved visits/units, effective dates, expiration dates, and payer requirements.
Communicate authorization decisions and updates to clinical and administrative teams.
Follow up with insurance companies and managed care organizations regarding pending authorization requests.
Identify missing or incomplete documentation that may delay authorization and work with the appropriate department to obtain it.
Assist with resolving authorization denials, requests for additional information, and other payer-related issues.
Escalate urgent authorization issues that may affect patient care or service continuity.
Maintain knowledge of payer-specific authorization requirements and procedures.
Utilize payer portals, telephone systems, fax systems, and electronic communication to submit and track authorization requests.
Maintain confidentiality of patient information and comply with HIPAA requirements.
Maintain accurate records and reports related to authorization activity.
Work collaboratively with intake, clinical, billing, scheduling, and management teams.
Perform other duties as assigned.