Prior Authorization Specialist

PUTNAM COUNTY HOSPITAL•Greencastle, IN

1d•Onsite

About The Position

The Prior Authorization Specialist obtains prior authorizations for imaging and procedures from appropriate payors. This role involves maintaining ongoing tracking and documentation of prior authorizations to promote team awareness and ensure patient safety. The specialist is responsible for complete and accurate registration, including patient demographic and current insurance information. They will assemble information concerning the patient's clinical background and referral needs, providing appropriate clinical information to specialists per referral guidelines. The role also includes contacting review organizations and insurance companies to ensure prior approval requirements are met, presenting necessary medical information to maximize reimbursement, and reviewing prior authorization details with patients as needed. Ensuring timely addressing of prior authorizations and identifying/utilizing cultural and community resources are key aspects. The specialist must abide by HIPAA and Hospital policies & procedures, assist with referrals, and perform other assigned duties.

Requirements

Knowledge of prior authorizations process for different services (radiology, pharmacology & laboratory services) and insurance providers (commercial, Medicare & Medicaid).
Solid understanding and knowledge of payer contractual requirements.
Experience with insurance verification.
Experience and familiarity with using insurance portals.
Previous clinical support experience (2 years) in a healthcare setting.
Basic knowledge of CPT & ICD 10 codes.
Working knowledge of anatomy, physiology & the disease process to effectively communicate medical necessity criteria for procedures ordered or to effectively appeal an adverse determination.

Responsibilities

Obtain prior authorizations for imaging and procedures from appropriate payors.
Maintain ongoing tracking and appropriate documentation on prior authorizations to promote team awareness and ensure patient safety.
Ensure complete and accurate registration, including patient demographic and current insurance information.
Assemble information concerning patient's clinical background and referral needs. Per referral guidelines, provide appropriate clinical information to specialist.
Contact review organizations and insurance companies to ensure prior approval requirements are met. Present necessary medical information such as history, diagnosis and prognosis.
Provide specific medical information to financial services to maximize reimbursement to the hospital and physicians.
Review details and expectations about the prior authorization with patients as needed.
Ensure that prior authorizations are addressed in a timely manner.
Identify and utilize cultural and community resources. Establish and maintain relationships with identified service providers.
Abide by HIPPA and Hospital policies & procedures.
Assists with Referrals as needed.
Performs other duties as assigned.