Summary

To assist Saunders Medical Center (SMC) Rural Health Clinic, Specialty Clinics and other services of Saunders Medical Center with obtaining prior authorizations for patient procedures. The Prior Authorization Specialist provides detailed and timely communication to both the payers and clinical partners in order to facilitate compliance with payer requirements and is responsible for documenting the appropriate information in the patients record. This position is under the supervision of the Care Coordinator Supervisor.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. 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.

• Contact patient insurance companies to obtain prior authorizations as indicated.
• Obtain benefit verification for cases as needed.
• Keep all on-line web portals active to ensure access is maintained in order to obtain or verify prior authorizations.
• Maintain records of all prior authorization status', actions and outcomes in the electronic medical record.
• Monitor trends for prior authorizations and communicate these with SMC clinic staff, providers and business office supervisor as appropriate.
• Appropriately prioritizes workload to ensure the most urgent cases are handled in a timely manner.
• Ensures timely and accurate insurance authorizations are in place prior to services being rendered.
• Keep up to date with prior authorization requirements, changes and share these as appropriate with department leaders.
• Communicate regularly with other departments within SMC regarding prior authorizations and educate staff as needed to ensure needs are being met for authorizations.
• Develop and maintain working relationships with external agencies and providers who have specialty clinics at SMC regarding prior authorizations.
• Utilize customer service skills in engaging teams, customers, insurers as needed.
• Provide documentation to include authorization numbers, CPT codes, diagnosis and approval dates in the EMR as well as reference number if no authorization is required.
• Send medical records pertaining to authorizations as needed.
• Understand the billing process to identify and communicate codes that may be required for reimbursement.
• Participate in Saunders Medical Center committees as approved by supervisor.
• Maintain a professional environment.
• Participate in quality assurance and improvement as assigned.
• Perform all duties with legal limitations as properly authorized, delegated or assigned.
• Practice the proper fire, safety and disaster procedures as set forth by SMC.
• Participate in all quality, safety, security and infection control programs that are mandatory as well as those required and provided by the department.
• Uphold confidentiality and HIPAA compliance at all times and report violations to the Privacy Officer.
• Understand and comply with the requirements of the Saunders Medical Center’s Compliance Program, including, but not limited to the Code of Conduct, the Compliance Policy, all Saunders Medical Center-wide policies for compliance, and compliance plans affecting specific duties and responsibilities.
• Participate in all education and training programs regarding compliance as required by Saunders Medical Center policy and as requested by the Supervisor.
• Demonstrate personal traits of a high-level commitment, motivation and energy; team orientation; professionalism; trust; personal honesty and integrity; and a demonstration of placing others in a place of high value and treating them with dignity and respect.
• Other duties as assigned.

Supervisory Responsibilities

None.

Disclosure Statement

The above statements reflect the general details considered necessary to describe the essential functions of the job as identified, and shall not be considered as a detailed description of all work requirements that may be inherent in the position.

Education and/or Experience

Minimum of two years of experience in pre-authorizations or insurance verification with demonstrated knowledge of health insurance plans.

Experience communicating with insurance companies and awareness of prior authorizations processes preferred. Knowledge of medical terminology.

Demonstrated ability to efficiently organize work and maintain a high level of accuracy and productivity.

Excellent typing and computer skills.

Certificates Licenses, Registrations

Maintain any certifications or licenses according to education.

Language Skills

Must be able to read, write and follow written and oral instructions and possess positive skills in communication. Ability to deal tactfully with personnel, patients, visitors, and the general public.

Mathematical Skills

Ability to calculate at the level necessary to perform essential duties of the position.

Reasoning Ability

Ability to make independent decisions when circumstances warrant such action. Ability to interpret a variety of instructions furnished in oral, written, 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.

While performing the duties of this job, the employee must stand frequently. The employee must sit, reach with arms and hands and occasionally lift 50 pounds. The employee must occasionally walk and climb or balance.

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 of this position. Attendance is essential and required for a successful working environment.

Typical medical clinic office environment.