Pre-Authorization Rep

CommonSpirit Health•Burien, WA

About The Position

As a Pre-Authorization Representative, you will be responsible for ensuring a smooth and efficient pre-admission and pre-authorization process for all patients, safeguarding necessary financial clearance before services are rendered. Daily, you will accurately gather and verify patient demographic and insurance information, obtain necessary pre-certifications and authorizations from insurance companies, and communicate financial responsibilities to patients. You will serve as a key point of contact, coordinating with physicians' offices, insurance providers, and hospital departments to facilitate seamless patient access to care. Your work directly contributes to preventing claim denials and ensuring financial integrity. Success in this role requires meticulous attention to detail, strong knowledge of insurance practices and medical terminology, excellent communication skills, and a commitment to patient advocacy and financial accuracy. Receives physician referrals and/or monitors work queue to identify for notification of patient’s pharmacy therapy plan and initiates process to validate insurance coverage and obtain pre-authorization for specific drugs/medications. Reviews insurance company requirements to identify acceptable documentation for pre-authorization of specific drugs/medication; maintains current awareness of frequent market changes and updates by various insurance/drug companies as to what constitutes medical necessity, which medications require pre-authorization and the specific documentation requirements. Reviews patient data in Epic to determine whether it is sufficient to meet the insurance company’s documentation requirements for specific medications; receives calls from insurance companies requesting additional documentation if not available in the patient’s medical record. Contacts physician’s offices as necessary to request specific documentation needed for pre-authorization, re-authorization and/or proof of medical necessity; may review patient’s chart notes, lab results, and medical history relating to previous diagnoses and/or drug regimens in order to gather/provide documentation that meets the differing needs of a specific insurance company and facilitate authorization. Contacts pharmacy, once pre-authorization has been obtained, to determine whether drug/medication is currently in stock; follows up to assure order has been placed and when it will be available; maintains ongoing communication with Conifer to advise when medication will be in stock for the patient. Recognizes when additional assistance is needed to resolve insurance pre-authorization issues and escalates appropriately and timely through defined communication and escalation channels.

Requirements

Two years of related work experience that demonstrates attainment of the requisite job knowledge and abilities.

Responsibilities

Ensuring a smooth and efficient pre-admission and pre-authorization process for all patients
Gathering and verifying patient demographic and insurance information
Obtaining necessary pre-certifications and authorizations from insurance companies
Communicating financial responsibilities to patients
Coordinating with physicians' offices, insurance providers, and hospital departments
Preventing claim denials and ensuring financial integrity
Receives physician referrals and/or monitors work queue to identify for notification of patient’s pharmacy therapy plan and initiates process to validate insurance coverage and obtain pre-authorization for specific drugs/medications.
Reviews insurance company requirements to identify acceptable documentation for pre-authorization of specific drugs/medication; maintains current awareness of frequent market changes and updates by various insurance/drug companies as to what constitutes medical necessity, which medications require pre-authorization and the specific documentation requirements.
Reviews patient data in Epic to determine whether it is sufficient to meet the insurance company’s documentation requirements for specific medications; receives calls from insurance companies requesting additional documentation if not available in the patient’s medical record.
Contacts physician’s offices as necessary to request specific documentation needed for pre-authorization, re-authorization and/or proof of medical necessity; may review patient’s chart notes, lab results, and medical history relating to previous diagnoses and/or drug regimens in order to gather/provide documentation that meets the differing needs of a specific insurance company and facilitate authorization.
Contacts pharmacy, once pre-authorization has been obtained, to determine whether drug/medication is currently in stock; follows up to assure order has been placed and when it will be available; maintains ongoing communication with Conifer to advise when medication will be in stock for the patient.
Recognizes when additional assistance is needed to resolve insurance pre-authorization issues and escalates appropriately and timely through defined communication and escalation channels.