Prior Authorization Specialist

Texas Tech University•El Paso, TX

About The Position

Responsible for verifying insurance coverage and eligibility, and obtaining required pre-authorizations for medical procedures, treatments and services. Handle authorization process and obtain pre-certification approvals prior to service. Submit pre-authorization requests and follow up with payer to ensure timely approvals. Update resident providers and supervising faculty of delays related to pre-authorization. Assist providers with treatment plan assessment to determine if pre-authorization is required. Assist in the development and maintenance of a standardized workflow for the pre-authorization process. Provide instruction and guidelines on coding and pre-authorization processes to faculty, residents and staff. Assist in the preparation and submission of appeals for denied authorizations, including but not limited to providing additional information or documentation. Respond and follow-up to patient and insurance inquiries/correspondence in a timely manner and in accordance with departmental expectations/requirements. Provide leadership team with regular status updates on authorization and denials. Maintain accurate records and reports of pre-certifications request, approvals, and denials. Review assigned electronic health record (EHR) Work Queue’s to ensure all errors are cleared and billing has been submitted in a timely manner, and in accordance with departmental expectations/requirements. Stay current with changes in coding guidelines, insurance regulations and insurance requirements. Assess and monitor Medicaid/CHIP billing guidelines and regulations while partnering with the Office of Institutional Compliance on corrective action plans related to billing compliance. Collaborate with revenue cycle team via weekly, biweekly, and/or monthly meetings (as directed) to review payment and denial trends. Collaborate with members of clinic administration on process improvement to help optimize the pre-authorization processes in the clinics. Communicate with patients regarding authorization requirements, status updates and financial responsibilities associated with approved or pending authorizations. Serve as a liaison between clinical providers and insurance payers to address authorization-related issues or inquiries effectively. Escalate matters of concern to leadership in accordance with departmental expectations/requirements. Remain current with all licensure, certifications and mandatory compliances and trainings required of this position. Adhere to all policies, procedures and practices (Regents Rules, TTUS, HSECEP OPs, etc.). Personally, and consistently, demonstrate, display and act in accordance with Texas Tech Health El Paso’s Values (Service, Respect, Accountability, Integrity, Advancement, and Teamwork). Serve as a Value's leader while actively promoting and encouraging staff across the institution. Perform all other duties as assigned.

Requirements

PACS, CHAA or CMA certification.
Knowledge of basic medical terminology.
Knowledge of CPT and ICD-10 coding.
Familiarity with payer authorization processes.
Ability to apply a strong attention to detail to work while meeting required deadlines, targets, goals, and/or metrics.
Associate's degree plus one (1) year of experience directly related to the processing of prior authorizations; OR High school diploma or GED plus current certification as a Prior Authorization Certified Specialist (PACS), Certified Healthcare Access Associate (CHAA), or Certified Medical Assistant (CMA); OR High school diploma or GED plus three (3) years of experience directly related to patient registration, patient scheduling, patient billing/collections, and/or the processing of prior authorizations.

Nice To Haves

Previous experience providing support to multiple medical sub-specialties/clinics.
Previous experience working in an academic medical/health sciences center.
Bilingual in English and Spanish.
Excellent communication (verbal and written) and interpersonal skills.

Responsibilities

Verify insurance coverage and eligibility.
Obtain required pre-authorizations for medical procedures, treatments, and services.
Handle the authorization process and obtain pre-certification approvals prior to service.
Submit pre-authorization requests and follow up with payers for timely approvals.
Update resident providers and supervising faculty on pre-authorization delays.
Assist providers with treatment plan assessment to determine if pre-authorization is required.
Assist in developing and maintaining a standardized workflow for the pre-authorization process.
Provide instruction and guidelines on coding and pre-authorization processes to faculty, residents, and staff.
Assist in preparing and submitting appeals for denied authorizations.
Respond to and follow up on patient and insurance inquiries/correspondence.
Provide regular status updates to the leadership team on authorizations and denials.
Maintain accurate records and reports of pre-certification requests, approvals, and denials.
Review EHR Work Queues to ensure errors are cleared and billing is submitted timely.
Stay current with changes in coding guidelines, insurance regulations, and insurance requirements.
Assess and monitor Medicaid/CHIP billing guidelines and regulations.
Collaborate with the revenue cycle team to review payment and denial trends.
Collaborate with clinic administration on process improvement for pre-authorization processes.
Communicate with patients regarding authorization requirements, status updates, and financial responsibilities.
Serve as a liaison between clinical providers and insurance payers.
Escalate matters of concern to leadership.
Remain current with all licensure, certifications, and mandatory compliances and trainings.
Adhere to all policies, procedures, and practices.
Demonstrate and act in accordance with Texas Tech Health El Paso’s Values.
Serve as a Values leader and promote staff engagement.
Perform all other duties as assigned.