Prior Authorization Specialist

Description

SUMMARY 

Compile, maintain and support timely and accurate completion of the health information of patients at KHS, Making information available to authorized users timely. Maintain storage and retrieval of health information. Assist in monitoring and resolving deficiencies, accurate data entry for clinical, financial and statistical purposes.

ESSENTIAL DUTIES AND RESPONSIBILITIES 

To be carried out in accordance with KHS and regulatory entities policies and procedures including, but not limited to, the following:

• Receive requests for prior authorizations through the electronic health record (EHR) and/or via phone or fax and ensure that they are properly and closely monitored.
• Process referrals and submit medical records to insurance carriers to expedite prior authorization processes.
• Knowledge of CPT, ICD-10 and HCPCS codes.
• Manage correspondence with insurance companies, physicians, specialist and patients as needed, including documenting in the EHR as appropriate.
• Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed.
• Review accuracy and completeness of information requested and ensure that all supporting documents are present.
• Review denials and follow up with provider to obtain medically necessary information to submit an appeal of the denial.
• Prioritize the incoming authorizations by level of urgency to the patient
• Maintain records according to regulatory and facility guidelines.
• Prepare, file and or scan records/documents in designated areas according to applicable filing/scanning system.
• Ensure quality and integrity of scanned data
• Operates computer and department software to enter and retrieve data and create correspondence and or reports.
• Responsible for data entry into hospital, clinic and other record systems for clinical, financial, and statistical purposes
• Answer telephone, route calls, take messages, and provide assistance and guidance to customers promptly and courteously 
• Interact positively with patients and public
• Maintain Constructive Relationships with all internal and external customers
• Attends and participates in approved/requested committees and meetings.
• Maintains current knowledge and skills through in-services, workshops, and/or seminars.
• Demonstrates flexibility in adjusting to variable workloads and job duties.
• Maintain confidentiality of all patients, clients and facility information at all times.
• Any other duties as assigned.

Requirements

QUALIFICATIONS  

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE 

A two-year associate degree in health information management is preferred. Must have basic computer skills. Must possess high school diploma or its equivalent. One year of related experience and/or training; or equivalent combination of education and experience. 

SKILLS

Typing and computer skills, strong organizational skills, detail oriented, excellent interpersonal/communication skills, basic knowledge of medical record content. Must be able to process work meeting acceptable benchmarks and deadlines/timeframes. Ability to effectively present information and respond to questions from supervisors, patients, patient's family, other employees of the organization and the general public.

REASONING ABILITY 

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

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.

• Light physical effort: ability to lift or carry up to 10 pounds regularly
• Mostly sedentary work
• Occasional standing and walking
• Ability to communicate verbally
• Close vision and distance vision.

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, the employee is exposed to hazards from electrical/mechanical/power equipment. Uses computer equipment extensively. The noise level in the work environment is usually quiet. May occasionally require irregular hours.