Pre-Authorization Specialist

Position Summary

The Pre-Authorization Specialist is responsible for identifying prior auth requirements by insurance/payer and processes and completes prior authorizations for scheduled and add on services. Determines if services are a covered benefit and documents pre-authorization information in Epic. Communicates with the ordering Provider's office if services were approved or denied to reduce denials and facilitates peer to peer reviews when needed.

Qualifications

EDUCATIONAL REQUIREMENTS

Associate's Degree or Certificate in NAHAM

Certification & Licensure Requirements

Completion of Medical Terminology course within one (1) year of start date in position.

Experience Requirements

Healthcare/Insurance experience of one (1) + year preferred

Additional Requirements

• Completion of Medical Terminology course within one (1) year of start date in position.
  

Skills And Knowledge

Strong verbal and written communication skills. Adept at learning and using software programs is essential. Demonstrated ability to organize and prioritize work and possess a strong attention to detail and follow up with minimal direction/supervision. Ability to work and collaborate with patients, nurses and physicians under stressful situations. Able to work independently and apply critical thinking skills when dealing with insurance scenarios for various payers. Able to navigate multiple payer websites to ensure requirements are met. Ability to handle large volume of pre-auths and multi task concurrently.

Essential Functions

• Analyzes information required to complete pre-authorizations based on multiple insurance/payer requirements; ensures coverage/insurance is correct.
• Proficiently utilizes third party payer/insurance portals to process pre-auth submissions; has a detailed knowledge of insurance providers, their portals and expectations for authorization approval.
• Documents pre-authorization results completely and communicates to leadership, Providers and/or Nurses pre-authorization approvals or denials.
• Advocates for patients/providers by processing pre-auths in a time sensitive manner and collaborating with physicians and nurses to secure clinical information needed for submissions.
• Coordinates peer to peer reviews for physicians and nurses.
• Identifies challenges, trends and patterns and works with management to address and resolve.
• Meets/succeeds pre-authorization productivity targets to meet dept. goals.
• Identifying prior auth requirements by insurance/payer and processes and completes prior authorizations for scheduled and add on services.
• Determines if services are a covered benefit and documents pre-authorization information in Epic.
• Communicates with the ordering Provider s office if services were approved or denied to reduce denials and facilitates peer to peer reviews when needed.
  

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: [email protected].

Effective September 20, 2021, the COVID 19 vaccine is required for all new Carle Health team members. Requests for medical or religious exemption will be permitted. With an approved exemption, healthcare workers must do weekly testing and verify a negative COVID-19 test.