Prior Authorization Specialist

MARYLAND PRIMARY CARE PHYSICIANS LLC•Bowie, MD

20d•$20 - $24

About The Position

The Prior Authorization Coordinator services patients, providers, and Health Plan representatives by handling provider referrals, facilitating clinical review, issuing authorizations, and coordinating referral services. The role uses pre-approved screening criteria in compliance with client requirements and adopted clinical guidelines, and handles complex treatment and authorization requests and provider inquiries. The position processes authorization requests for services including diagnostic imaging, prescription medications, Home Health, and Durable Medical Equipment. It verifies member eligibility and benefits, gathers required records, enters and tracks requests, coordinates approved services, maintains records, and communicates with internal and external parties. The role also protects sensitive health information in accordance with company HIPAA policies and procedures.

Requirements

High school diploma or GED.
Computer literacy and advanced data-entry capacity of more than 45 words per minute.
Three to five years of experience in a medical office setting.
Two years of experience processing or managing referrals or authorization requests in a Utilization Management department, with production and accuracy well above minimum goals; an equivalent combination of education and experience may qualify.
MMR, TB, and flu requirements are listed in the posting.

Nice To Haves

Medical coding or authorization education or training preferred.

Responsibilities

Obtain prior authorizations for diagnostic imaging, prescription medications, Home Health, and Durable Medical Equipment.
Receive provider and Health Plan referral requests and assist with processing medical service requests and related clerical duties.
Verify member eligibility and benefits and notify designated staff of eligibility issues.
Accurately enter requests received by fax or phone into the system for electronic authorization generation and tracking.
Provide service authorizations to providers in accordance with departmental policies, procedures, and client processes, within required timeframes.
Request appropriate medical records according to established criteria and applicable policies and procedures.
Notify required parties within the appropriate timeframe for routine and urgent service requests.
Research member history for duplicate requests and authorization limits.
Verify fax numbers and update systems; contact requesting providers to clarify authorization requests, including codes, timeframes, or member demographics.
Communicate effectively with internal and external parties.
Forward authorizations to appropriate department staff for eligibility, coverage, pricing, and benefit issues.
Scan, attach, and review electronic images, and record required attachment information in authorization fields.
Collaborate with the Supervisor and insurance companies to resolve complex authorization issues.
Forward referral requests to the next level of clinical review when applicable, after checking completeness and appropriateness.
Coordinate approved outpatient surgical procedures with specialist offices or outpatient surgical facilities and Health Plan authorization departments when applicable.
Coordinate approved services with Home Health and Durable Medical Equipment providers, Nurse Care Managers, Plan discharge planners, and Plan members as delegated or required.
Serve as a resource for PCP referrals to network specialists.
Maintain logs, records, and reports as established.
Document and communicate areas of concern to the supervisor.
Identify providers who need education on national, state, and Plan requirements.
Follow company HIPAA policies and procedures, protecting sensitive PHI and ensuring its security.
Perform other duties as assigned.