Job Description

ESSENTIAL FUNCTIONS of this job description include but are not limited to:

• Review chart documentation to ensure patient meets medical policy guidelines
• Prioritize incoming authorization requests according to urgency
• Obtain authorization via payer website or by phone and follow up regularly on pending cases
• Maintain individual payer files to include up to date requirements needed to successfully obtain authorizations
• Initiate appeals for denied authorizations
• Utilizes telephone courtesies on all telephone interactions
• Obtains accurate and complete information for hospital consults and forwards to the appropriate Clinicians according to practice protocols
• Accurately enters new & established patient information in the computer/scheduling program.
• Obtains all insurance information for patient appointments according to practice protocols
• Schedules patient appointments accurately according to individual provider’s scheduling template and follows practice protocols regarding approval for exceptions/add-ons
• Respond to clinic questions regarding payer medical policy guidelines
• Confirm accuracy of CPT and ICD-10 diagnoses in the procedure order
• Contact patients to discuss authorization status  
• Maintains safe, secure, and healthy work environment by following, and enforcing standards and procedures; complying with legal regulations.
• Maintains strictest confidentiality; adheres to all HIPAA guidelines/regulations.
• Performs other tasks and duties as assigned in an efficient, effective and cost conscious manner, complying with all hospital policies, procedures, and regulations

KNOWLEDGE, SKILLS, QUALIFICATION and EDUCATIONAL AND /OR EXPERIENCE REQUIREMENTS:

• High School Diploma or GED
• 2 years medical prior authorization experience preferred
• 2 years experience in a medical related field required
• Knowledge of procedure authorization and its direct impact on the practice’s revenue cycle
• Understanding of payer medical policy guidelines while utilizing these guidelines to manage authorizations effectively
• Basic understanding of human anatomy
• Proficient use of CPT and ICD-10 codes
• Proficiency in Microsoft Office Suite
• Strong organizational and customer service skills
• Ability to:
  • determine appropriate course of action in more complex situations
  • work independently, exercise creativity, be attentive to detail, and maintain a positive attitude
  • manage multiple and simultaneous responsibilities and to prioritize scheduling of work
  • maintain confidentiality of all medical, financial, and legal information
  • complete work assignments accurately and in a timely manner
  • communicate effectively, both orally and in writing/electronically
  • handle difficult situations involving patients, physicians, or others in a professional manner
• Possesses good interpersonal skills, initiative, integrity, flexibility, adaptability, and must be a team player

PHYSICAL DEMANDS / WORKING CONDITIONS: 
Sitting, standing, walking bending/twisting, kneeling/squatting, reaching, climbing and should be able to lift 25 or more pounds using proper lifting techniques.  Rapidly changing and stressful environment.  Ability to communicate with various levels of people.  Possible exposure to communicable and infectious disease and hazardous materials. Occasional exposure to unpleasant patient or unit elements (accidents, injuries and illness). Contact with patients under a wide variety of circumstances.  Subject to varying and unpredictable situations.  Handles emergency or crisis situations.  Subject to many interruptions.  Occasional pressure due to multiple tasks and inquiries. 

The information in this job description is intended to describe the general nature and level of work being performed by people assigned to this classification and requirements for the performance of this job.  They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.

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