Title: | Insurance Pre-Authorization Specialist |
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ID: | 1041 |
Department: | Business Office |
Hours per Week: | 40 |
Salary Range: | DOE |
Shift: | N/A |
General Scope of Work: Oversees the process of incoming patient orders and obtains information necessary to complete the pre-authorization and scheduling of an order. This process includes collecting all the necessary documentation, contacting the referring physician or their office for additional information or to ask questions regarding the order, and determining from a quick overview whether the order is likely to be approved (pre - pre-auth) and is ready to be moved on to pre-authorization stage. This position will also be responsible for the completion of the required pre-authorization process for obtaining insurance and Medicare/Medicaid payment approval prior to the scheduling of an order.
PRIMARY DUTIES AND RESPONSIBILITIES:
Patient Order Expediting and Pre-Authorization for Services
1. Maintains process for identifying and prioritizing orders for scheduled services requiring pre-authorization
2. Obtains pre-authorization for ED and Floor Discharge Directed Services
3. Contacts ordering physician’s offices for demographic, diagnostic and clinical information needed to complete pre- authorization
4. Reviews documentation from ordering physician to meet the needs of the payee
5. Verifies diagnosis code on patient billing is accurate and reimbursable/payable
6. Works with patients’ insurance companies to pre-certify/authorize services as ordered by the referring physician.
7. Communicates with departments as needed to keep them updated
8. Communicates with customers to request additional documentation as needed
9. Utilizes Centriq to document pre-authorization numbers and notes pertaining to acquiring pre-authorization
9. Assists with any denied claims to resolve any issues
Medical Necessity
1. Assists Departments with obtaining the appropriate diagnosis from the ordering physician for non-scheduled services
2. Identifies Local and National Coverage Determinations (LCDs and NCDs) to create departmental checklists and aids in providing services only after required interventions and/or documentation prior to the scheduled service.
3. Educates and assists departments in medical necessity determinations and collaborating with ordering physician offices for appropriate testing
4. Utilizes Centriq in automated processes of determining medical necessity of services
Other Duties
1. May assist with scheduling as needed
2. Authorization file maintenance
3. Authorization and Medical Necessity denial audits
The job description reflects management assignment of essential functions; it does not prescribe or restrict the tasks that may be assigned.
POSITION QUALIFICATIONS:
EDUCATION, CERTIFICATIONS AND LICENSES:
1. High school diploma required
2. Medical Billing or Coding certifications (or equivalent experience) a plus
SPECIFIC REQUIREMENTS:
1. Pre-certification knowledge/experience preferred
2. Prior experience with patient scheduling or working in a medical environment preferred
3. Previous billing, Medicare and private pay experience preferred
4. Knowledge of CPT, HCPCS and some knowledge of ICD-10 codes preferred
5. Familiarity with Medical Terminology preferred
6. Proven customer service skills
7. Able to work in a high volume/fast-paced environment
8. Ability to work with sensitive and confidential information
9. Operating knowledge of personal computers and MS Windows applications (including Word, Excel and Outlook)
10. Must possess superb communication skills
12. Must be able to function effectively in a team-oriented environment
13. Must be self motivated and able to work independently with limited direction
14. Must be reliable and demonstrate sound judgment and initiative
15. Possess a high degree of accuracy in work output