Medication Prior Authorization Coordinator

Baystate Health • Springfield, MA

1d • Onsite

About The Position

The Referral Authorization Coordinator is responsible for providing a variety of support services that are essential to the efficient operation of ten pediatric specialty practices' centralized process for insurance verification and authorization. Demonstrates excellent communication, interpersonal communication, critical thinking, and problem solving skills. Uses CIS as a means of multidisciplinary communication. Completes all appropriate forms, applications, and information for departmental statistics. Accurately manages the referral and authorization process in a timely manner. Able to meet time-sensitive timelines for care treatment. Is pro-active in troubleshooting instances which could result in great financial loss. Demonstrates excellent customer service skills and works in a positive manner for collaboration and clear communication between providers, staff, insurers, and families. The specialist works closely with the clinical department staff, Care Coordinator, Social Service staff as well as the business services staff in the performance of duties for information gathering and patient data. Participates in departmental meetings and meets all timelines for reports. Meets expectations for less than one week turnaround for majority of prior authorization approvals.

Requirements

• 3-5 years Medical Registration, Billing, and/or Medical Assistant in a busy primary or specialty practice or billing office
• Knowledge of medical terminology preferred
• Proficiency in Microsoft Office, Word, and Excel
• Solid verbal and written communication skills
• Demonstrates a high degree of self motivation and self direction
• Experience with CIS inbox, Centricity Business and EMR a plus
• GED or HiSET

Nice To Haves

• Bilingual (English/Spanish) preferred
• Previous experience with medication insurance prior authorizations.

Responsibilities

• Processes prior authorizations through medical and pharmacy benefits for medications for infusions and injections.
• Ensures all referrals and authorizations are obtained and processed in a timely fashion on both a complex and as-needed basis. Completes prior authorizations and referrals for services and testing in both A and B spaces. Develops and maintains a centralized prior authorization process utilizing all available systems.
• Enters referrals and authorizations into the system per standardized practice protocols/departmental guidelines and provides feedback to ordering provider and patient/parent in a timely manner. Monitors linkage of authorizations and referrals to appointments in Centricity, ensures compliance to insure proper payment for services provided.
• Consistently monitors and works denial and no referral reports to obtain prior authorizations and referrals. Coordinates and processes documentation necessary for insurance appeals related to referral and authorization as well as other appeals as necessary for services. Works with key stakeholders to track the denial and appeal process.
• Maintains solid knowledge of utilization, billing, and reimbursement practices as well as special payor agreements specific to pediatric specialties. Prevents denials by identifying and documenting payor requirements for utilization management by employing a variety of methods including websites, contracts, policy manuals, bulletins, and other subject matter experts.
• Coordinates and maintains the Electronic Referral Tracking Report for accuracy of information, urgency, and other designated criteria.
• Documents and provides updates in the patient's medical record regarding the status of the referral and/or authorization.
• Assists with billing and coding issues within 10+ divisions. Assists patient/families with billing, coding, and insurance issues.
• Act as a resource to all internal and external customers, offering guidance and support for referral and authorization related questions and processing problems. Ensures patients/families receive timely and courteous communications.
• Provides in-service training to staff and other Baystate departments to explain referral/prior authorization process and methods to prevent non-payment. Works with staff and management to insure proper and accurate gathering and recording of payor information.
• Assists divisions with complex, multi-study bookings (CT, MRI, PSG) that need to be booked together for family convenience and patient comfort.
• Maintains statistical information and reports as directed. Participates in and drives process change to improve efficiency and decrease denials.
• Coordinate strategy and re-evaluate claims to be written off by PBO in effort to exhaust all payment possibilities. Track reimbursement recovered.

Benefits

• The compensation range(s) in the table below represent the base salaries for all positions at a given grade across the health system. Typically, a new hire can expect to start somewhere in the lower part of the range. Actual salaries may vary by position and will be determined based on the candidate's relevant experience. No employee will be paid below the minimum of the range. Pay ranges are listed as hourly for non-exempt employees and based on assumed full time commitment for exempt employees. Minimum - Midpoint - Maximum $60,944.00 - $70,054.00 - $82,846.00

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED
• Number of Employees: 5,001-10,000 employees