Prior Auth

Vista Healthcare•St. George, UT

3d•Onsite

About The Position

Essential Functions/Responsibilities: Answer calls from patients and physician offices using exemplary customer service skills. Accurately enter required information, non-clinical and clinical, into computer database. Review clinical data matching it against specified medical criteria and follow established procedures for authorizing request for further review. Review incoming orders for completeness to determine if procedure ordered will be covered by insurance (in some cases, pre-certification is not warranted). Complete follow-up with physicians for orders still waiting for documentation. Contact physicians offices to obtain missing documentation to complete orders. Works with patients insurance companies to pre-certify/authorize procedures as ordered by the referring physician. Contact ordering physician with update if procedure is denied and assist with scheduling peer to peer reviews, if needed. Once order is complete, contact patient to confirm receipt of order and inform patient he/she will receive a scheduling call once insurance has been approved. Monitor pre-certification status to ensure timely processing and completion. Log order into the appropriate authorization spreadsheet and schedule procedure once approved. Maintain patient confidentiality as defined by state, federal and company regulations. Establish effective rapport with other employees, professional support service staff, customers, clients, patients, families, and physicians. Actively support departmental and corporate strategic plans and ensure successful implementation. Maintain cooperative working relationships with all clinics and providers.

Requirements

Six months previous experience in medical prior authorization. Will train right person
Knowledge of CPT and ICD-10 codes.
Familiarity with medical terminology.
High School Education or GED.
Ability to interact with patients, insurers and office team members in a responsible, professional and ethical manner.
Must be able to function effectively in a team-oriented environment.
Must be able to work independently with limited direction.
Must be reliable and demonstrate sound judgment and initiative.
Able to work in a high volume/fast-paced environment.

Responsibilities

Answer calls from patients and physician offices using exemplary customer service skills.
Accurately enter required information, non-clinical and clinical, into computer database.
Review clinical data matching it against specified medical criteria and follow established procedures for authorizing request for further review.
Review incoming orders for completeness to determine if procedure ordered will be covered by insurance (in some cases, pre-certification is not warranted).
Complete follow-up with physicians for orders still waiting for documentation.
Contact physicians offices to obtain missing documentation to complete orders.
Works with patients insurance companies to pre-certify/authorize procedures as ordered by the referring physician.
Contact ordering physician with update if procedure is denied and assist with scheduling peer to peer reviews, if needed.
Once order is complete, contact patient to confirm receipt of order and inform patient he/she will receive a scheduling call once insurance has been approved.
Monitor pre-certification status to ensure timely processing and completion.
Log order into the appropriate authorization spreadsheet and schedule procedure once approved.
Maintain patient confidentiality as defined by state, federal and company regulations.
Establish effective rapport with other employees, professional support service staff, customers, clients, patients, families, and physicians.
Actively support departmental and corporate strategic plans and ensure successful implementation.
Maintain cooperative working relationships with all clinics and providers.