Prior Authorization Specialist

Putnam County Hospital•Greencastle, IN

About The Position

The Prior Authorization Specialist is responsible for obtaining prior authorizations for imaging and procedures from appropriate payors. This role involves maintaining ongoing tracking and documentation of prior authorizations to ensure patient safety and team awareness. The specialist will also ensure complete and accurate patient registration, including demographic and insurance information, and assemble clinical background information for referrals. They will communicate with review organizations and insurance companies, presenting necessary medical information to secure prior approval and maximize reimbursement. Additionally, the role includes reviewing prior authorization details with patients, addressing them in a timely manner, identifying and utilizing cultural and community resources, and maintaining relationships with service providers. The specialist must adhere to HIPAA and Hospital policies & procedures, assist with referrals as needed, 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.
Provide appropriate clinical information to specialist per referral guidelines.
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.