Prior Authorization Rep Sr

Hennepin Healthcare•Minneapolis, MN

1d•Remote

About The Position

The Prior Authorization Specialist plays a key role in the patient financial experience by coordinating pre-authorizations for patients and often handling cases that need quick turnaround (e.g., last-minute scheduled services). The individual in this role is an expert on payer regulations and contracts, and they serve as a point of contact for peers looking to resolve questions or issues regarding prior authorizations.

Requirements

High school diploma or equivalent
2 years clerical experience in health care revenue cycle operations: billing/claims, patient accounting, collections, admissions, registration, etc.
Requires knowledge of government and commercial payer (Insurance) benefit and eligibility verification, and ability to become aware of and navigate medical policy per payer guidelines
Demonstrated expertise in logical thinking, data preparation, and analysis
Comprehensive knowledge of Microsoft Office (Outlook, Word, Excel)
Strong communication skills, both verbal and written
Ability to communicate effectively with collaborating departments, providers, and insurance representatives
Demonstrated organizational skills and the ability to prioritize and manage tasks based on established criteria
Excellent verbal and written communication and interpersonal skills
Ability to work independently with minimal supervision, within a team setting and be supportive of team members
Proficient with Microsoft Office
Ability to analyze issues and make judgments about appropriate steps toward solutions

Nice To Haves

Bilingual strongly preferred, required in some positions
Experience working in EPIC, preferred

Responsibilities

Utilizes online systems, phone communication, and other resources to secure prior authorizations within a timeframe before scheduled appointments/procedures/same day surgeries and during or after care for unscheduled patients
Verifies medical necessity in accordance with the Centers for Medicare & Medicaid Services (CMS) standards and communicates relevant coverage/eligibility information to the provider/patient, as it pertains to prior authorization
Coordinates benefits by effectively determining primary, secondary, and tertiary liability when needed
Obtains pre-certifications and prior authorizations from third-party payers in accordance with payer requirements
Alerts physician offices to issues with verifying insurance and/or obtaining prior authorizations
Demonstrates expert understanding of insurance terminology (e.g., co-payments, deductibles, allowances, etc.), and analyzes information received to determine patients’ out-of-pocket liabilities, based on prior authorization status
Follows up on all prior authorization submissions for timely response
Follows up on any prior authorization denials; assists Utilization Management with appeals, as needed
Connects patients with financial counselors, as necessary
Maintains productivity and quality standards and assists other team members when necessary
Participates in developing and planning process improvements for the department
Other duties as assigned
Complies with all state and federal laws and regulations related to patient privacy and confidentiality