SUMMARY

The Authorization Specialist works with all clinical areas, physician clinics, and third party payers for the purpose of obtaining prior authorization or pre-certification and resolves appeals to ensure payment for services. Compliance with rules and regulations of all applicable federal, state and local laws as well as PMHC policies and Medical Staff rules and regulations is a condition of employment.

ESSENTIAL FUNCTIONS 

Incumbent must have the skills, ability and judgment to perform the following essential job duties and responsibilities with or without reasonable accommodation:

1. Obtains and reviews prior authorizations/precertification for all insurance carriers using carrier specific tools and or methods.
2. Monitors, tracks, and follows up on authorization/certification
3. Ensures order has an indication or reason for visit that is medically
4. Navigates websites for on-line insurance benefits review and authorization
5. Ensures the prior authorization or precertification is for the correct services ordered and CPT/HCPCS codes match.
6. Contacts referring physician offices to obtain prior authorization/precertification
7. Contacts the patient if any authorization/precertification
8. Initiates peer to peer reviews as needed
9. Assists Member Services, Claims and Provider Services insurance department staff with issues that require medical interpretation or definition to resolve appeals.
10. Maintains proficiency in reviewing medical records for evidence that care/services and need for care/services met the requirements of the patient’s insurance policy.
11. Assists with scheduling or rescheduling patients to accommodate authorization
12. Builds and maintains collaborative relationships with both internal and external clients that lead to more effective communication and a higher level of productivity and accuracy.
13. Performs phone reviews of prior authorization requests for appropriate care and approval of services or forward requests to the appropriate Physicians or Medical Directors with recommendations for other determinations.
14. When primarily in a remote position, there is an expectation of coming on-site for monthly department meetings and monthly stoplight meetings.

SUPERVISORY RESPONSIBILITIES

1. Directly responsible to the Director of Revenue

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use fingers to type, and use technical equipment such as a computer. The employee is occasionally required to stoop, kneel, or reach. The employee must occasionally lift and/or move up to 20 pounds. Specific vision abilities required by this job include near vision and the ability to adjust focus.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, employees the employee frequently works near moving mechanical parts and is frequently exposed to fumes or airborne particles and risk of electrical shock. The employee occasionally works with explosive, toxic or caustic chemicals. The noise level in the work environment is usually moderate.

The level of risk of exposure to blood borne pathogens is Classification (III), as outlined in the Hepatitis B Vaccine Program Policy.

The noise level in the work environment is usually moderate.

REQUIRED EDUCATION

1. Completion of certification in medical assisting or nursing or
2. Prior Authorization Certified Specialist program