Prior Authorization/Referral Specialist

POSITION PURPOSE

• A Prior-Authorization/Referral Specialist is responsible for determining insurance eligibility/benefits and ensuring pre-certification (authorization/referral) requirements are met for both the facility and professional services. The Prior-Authorization/Referral Specialist provides detailed documentation and communication with both payors and clinicians to obtain prior-authorizations. Obtains clinical information to support medical necessity.

MINIMUM EDUCATION REQUIRED

• High School or GED

MINIMUM EXPERIENCE REQUIRED

• 1-3 years

LICENSES / CERTIFICATIONS REQUIRED

• Formal education beyond high school in Business or Healthcare or equivalent experience preferred.

KNOWLEDGE, SKILLS & ABILITIES REQUIRED

• Experience in prior authorization/referrals, patient registration, insurance verification and health insurance plans.

• Knowledge on online insurance prior-authorization process and working with various payors.

• Excellent customer service and computer skills.

• Familiarity with Medical Terminology.

• Demonstrated ability to efficiently organize work, while maintaining a high level of accuracy and productivity.

• Knowledge of ICD-10, CPT and HCPC codes and use.

• Familiarity with internet, email and Microsoft Office.

• Effective written and verbal communication skills required.

PRINCIPLE ACCOUNTABILITIES AND ESSENTIAL DUTIES

• Verifies eligibility and benefit levels to ensure adequate coverage for identified services.

• Obtains pre-certification, authorization and referral approval for required services for both the facility and professional services.

• Calculates "billable units" for medication as identified by the payer rather than utilizing patient visits.

• Manages and resolves assigned departmental workqueues.

• Coordinates and supplies information to the review organization (payer) including clinical information and/or letter of medical necessity for determination of benefits. Coordinates peer-to-peer reviews, when required.

• Communicates with patients, clinicians, financial counselors and other as necessary to facilitate the authorization process.

• Completes accurate documentation in healthcare software.

• Completes inpatient notification to all payers using their preferred method within 24 hours of admission.

• Ensures timely and accurate insurance authorizations/referrals are in place prior to services being rendered.

• Notifies patient/department when authorization/referral has not been obtained prior to service date.