Pre-Authorization Representative

UHS•Aiken, SC

12h

About The Position

The Pre-Authorization Specialist is responsible for identifying prior authorization requirements by insurance /payer, processes, and obtains prior authorizations for scheduled and add on services. Determines if services are a covered benefit, obtains pre-authorization and documents information in CERNER. Communicates with the ordering Provider’s office if services were approved or denied and facilitates peer-to-peer reviews when needed to prevent denials and improve Physician satisfaction.

Requirements

Associate degree in business or related major preferred and or 5 years or more of directly related experience performing same or similar job function.
CHAA - (Certified Healthcare Access Associate) certification preferred.
Five (5) years' experience in a health care facility or equivalent position performing same or similar job duties required.
Medical Terminology completion preferred, understanding of third-party payer requirements (Authorization, verification and regulations).
Ability to receive and express detailed information through oral and written communication.

Nice To Haves

CHAA - (Certified Healthcare Access Associate) certification preferred.
Medical Terminology completion preferred, understanding of third-party payer requirements (Authorization, verification and regulations).

Responsibilities

Locates, reviews and obtains appropriate chart documentation from all sources (Physician, CERNER, etc.) based on payer requirements needed to obtain prior authorization for scheduled/ add-on IP and OP procedures/admissions/surgeries.
Communicates with physician office regarding status of authorization, information needed, facilitates, and completes peer-to-peer reviews when needed.
Initiate appeals for denied authorizations prior to service rendered avoiding denials and/or penalties to the facility.
Understands Insurance processing requirements i.e.; (verification, authorization, terms, requirements and regulations) and familiar with payer processes to obtain authorization in a timely manner.