Prior Authorization Specialist
About The Position
CentraState Medical Center is currently seeking a Prior Authorization Specialist. In this role, the specialist will review oncology therapy regimens and inpatient oncology admissions while also providing redundancy for radiation therapy, ensuring compliance with reimbursement guidelines. Responsibilities include securing pre-certifications, prior authorizations, and medical necessity approvals to prevent delays in treatment reimbursement. The specialist will also research denied services, explore alternative funding options, and monitor work queues through EPIC and/or Mosaiq. Additionally, they will collaborate with insurance companies on predeterminations, authorizations, and medical necessity verifications while tracking reports related to denials and other key processes.
Requirements
- High School Diploma Or Equivalent required.
- Minimum three (3) years medical insurance verification and authorization required.
- Oncology therapy experience required.
- Demonstrated working knowledge of contracts, insurance benefits, exclusions, and other billing requirements as well as claim forms, HMOs, PPOs, Medicare, Medicaid, and compliance program regulations.
- Ability to understand and navigate the payor adjudication process.
- Must possess a strong customer service and patient focused orientation.
- Demonstrated effective communication skills both verbally and written.
- Ability to multi-task, prioritize, and manage time effectively.
- Functional proficiency in computer software skills (i.e., Microsoft Word, Excel, Outlook, E-mail, etc.)
- Ability to work independently.
- Knowledge of medical terminology is required.
Nice To Haves
- Bachelor's Degree preferred.
- Patient financial and practice management system experience in Epic and or other of electronic billing systems is preferred.
Responsibilities
- Reviews, processes, and audits the medical necessity for each patient therapy treatment and all necessary required documentation.
- Communicates with nursing and medical staff to inform them of any restrictions or special requirements in accordance with insurance plans.
- Provides prompt feedback to physicians and leadership team regarding pathway documentation issues, and payer issues with non-covered chemotherapy drugs.
- Updates coding/payor guidelines for clinical staff. Tracks pathways and performs various other business office functions on an as needed basis.
- Obtains insurance authorization and pre-certification specifically for patient therapy services. Works as a patient advocate and functions as a liaison between the patient and payor to answer reimbursement questions and avoid insurance delays.
- Researches additional or alternative resources for non-covered therapy services to prevent payment denials.
- Provides a contact list for patient’s community resources including special programs, drugs, and pharmaceutical supplies and financial resources.
- Maintains thorough understanding and use of electronic medical record/s and payor websites.
- Adheres to confidentiality, state, federal, and HIPPA laws and guidelines with regards to patient’s records.
- Maintains a good working knowledge of therapy authorization requirements for all payors, state and federal regulatory guidelines for coverage and authorization.
- Works authorization queue daily and as needed.
- Performs other duties as requested or assigned.
Benefits
- Medical, Dental, Vision, Prescription Coverage (30 hours per week or above for full-time and part-time team members)
- Life & AD&D Insurance
- Long-Term Disability (with options to supplement)
- 403(b) Retirement Plan with employer match
- 401(a) Retirement Plan with employer contribution
- PTO
- Tuition Reimbursement
- Well-Being Rewards
- Employee Assistance Program (EAP)
- Fertility Coverage, Healthy Pregnancy Program
- Flexible Spending & Commuter Accounts
- Pet, Home & Auto, Identity Theft and Legal Insurance
- Growth Opportunity and Workforce Development Initiatives
- Continuing Education / Onsite Training
- A warm, welcoming company culture based upon mutual respect and a collaborative goal of providing excellent patient care
- Concierge Services with Work & Family Benefits
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
