Prior Authorization Specialist - Kelsey Seybold - Hybrid in Pearland TX
About The Position
Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation’s leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together. Position in this function is under the supervision of the Business Services Supervisor, the Prior Authorization Specialist (PAS) is responsible for processing incoming referral requests by contacting the Health plans verbally or electronically to obtain prior authorization for services provided and directed by a Kelsey provider. The PAS is responsible for communicating, obtaining and/or providing all required information to the health plans to facilitate the approval process, such as the medical record or an extract of clinical information from the medical record, and all pertinent information required to obtain prior authorization. The PAS also responsible for accurately verifying and/or documenting in the practice management system all pertinent information conducive to proper claim adjudication by the health plan, including, but not limited to authorization numbers, CPT codes approved, authorized dates, start and expiration date, call reference numbers, health plan representative’s first and last name, and payor portal screenshots. The PAS is responsible for initiating communication with the clinic/physician when a referral is denied and/or requires additional information, Peer to Peer Review, etc. The PAR is responsible for logging in to the designated phone queue to answer, direct and/or resolve any inquiries or directions regarding referrals. Additional duties include handling and appropriately directing referral status requests as needed. The PAS will also identify and report to the Management team any patterns, trends or workflow deficiencies that undermine department effectiveness. Other duties as assigned. You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Requirements
- High School diploma or GED from an accredited program
- 2+ years of medical office experience either in a physician office or hospital setting, health plan, ACO, or other managed care setting.
- Experience navigating payor web portals
Nice To Haves
- College level courses
- Experience with precertification and/or utilization management
- Knowledge of CPT & ICD 10 Coding methodologies
Responsibilities
- processing incoming referral requests by contacting the Health plans verbally or electronically to obtain prior authorization for services provided and directed by a Kelsey provider
- communicating, obtaining and/or providing all required information to the health plans to facilitate the approval process, such as the medical record or an extract of clinical information from the medical record, and all pertinent information required to obtain prior authorization
- accurately verifying and/or documenting in the practice management system all pertinent information conducive to proper claim adjudication by the health plan, including, but not limited to authorization numbers, CPT codes approved, authorized dates, start and expiration date, call reference numbers, health plan representative’s first and last name, and payor portal screenshots
- initiating communication with the clinic/physician when a referral is denied and/or requires additional information, Peer to Peer Review, etc
- logging in to the designated phone queue to answer, direct and/or resolve any inquiries or directions regarding referrals
- handling and appropriately directing referral status requests as needed
- identifying and report to the Management team any patterns, trends or workflow deficiencies that undermine department effectiveness
- Other duties as assigned
Benefits
- a comprehensive benefits package
- incentive and recognition programs
- equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements)
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
