Description

Statement of Purpose: This position is responsible for facilitating and processing prior authorization needs to ensure that patients receive timely and appropriate medical treatments. This position requires strong attention to detail, effective communication with healthcare providers, insurance companies, and patients, as well as in-depth understanding of healthcare regulations and payer requirements. The Prior Authorizations Specialist is organized, efficient, and knowledgeable about prior authorization procedures in a healthcare setting. In addition, the Prior Authorizations Specialist will collaborate with internal departments to gather necessary information, maintain accurate records, and provide exceptional customer service to both internal and external stakeholders.

 

CAN Values:

1. Recognize and affirm the unique and intrinsic worth of each individual.
2. Treat all those we serve with compassion and kindness.
3. Act with absolute honesty, integrity, and fairness in the way I conduct my business and the way I live my life.
4. Trust my colleagues as valuable members of our healthcare team and pledge to treat one another with loyalty, respect, and dignity.

Essential Functions:

1. Promotes and practices CAN Community Health Inc’s mission and values and follows its policies and procedures.
2. Ensures confidentiality is maintained by entire team regarding patient/client information in accordance with HIPAA, professional and departmental standards.

Primary Tasks:

1. Review and submit prior authorization requests for office visits, medical procedures, and/or medications as necessary, in accordance with insurance guidelines and company protocols.
2. Serve as a liaison between providers, insurance companies, and patients to ensure clear communication about authorization requirements, approvals, and denials.
3. Work closely with Care Connection Team to check patient insurance benefits to determine eligibility and requirements for prior authorization.
4. Maintain accurate records of prior authorization activities and ensure compliance with healthcare regulations and confidentiality laws, including HIPAA.
5. Monitor the status of prior authorization requests and follow up with payers to obtain timely approvals. Coordinate appeals when authorizations are denied.
6. Work closely with clinical staff, billing teams, and other departments to resolve issues related to prior authorizations and ensure a smooth workflow.
7. Takes patient calls and reviewing voicemails as needed.
8. Works closely with leadership to provide feedback on trends, issues, and necessary improvement needed relating to incoming referrals and authorizations.
9. Maintain up-to-date knowledge of insurance regulations, policies, and billing procedures.
10. Collaborate with the billing team, clinics, and other departments to improve processes, communicate concerns/issues, and improve revenue cycle efficiency.
11. Adhere to HIPAA regulations and maintain patient confidentiality.
12. Respond promptly to inquiries from internal and external stakeholders regarding billing issues or inquiries relating to authorizations.
13. Perform Value-Based Care related functions as it relates to prior authorizations and incoming referrals.

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Secondary Tasks:

1. Practice Integrity and Mission and Value statement.
2. This position overlaps with the Care Connection Team position and will rotate through various functions within the Care Connection Team. See Care Connection Team job description for further information.
3. Perform other duties as assigned by Care Connection Team and Revenue Cycle Leadership.
4. Works as a liaison with management team members to ensure successful flow of organization operations.

Physical Requirements:

1. Requires frequent bending, stooping, and standing. Requires visual and auditory acuity, frequent sitting and walking for extended periods of time.

Education/Professional:

1. High School Diploma required; Bachelor’s degree preferred.
2. Three -Five years minimum of Prior Authorizations Experience in a Healthcare environment.

Competencies:

1. Communication
2. Attention to Detail
3. Problem Solving
4. Results Driven
5. Interpersonal Skills
6. Customer Service

 

Knowledge, Skills and Abilities Required:

1. Ability to work with minimal supervision.
2. Ability to prioritize tasks and manage time effectively to meet deadlines.
3. Ability to research projects using primary sources when appropriate, such as CMS, HRSA, AHCA, etc.
4. Experience working with medical payers including Medicare, Medicaid, Commercial and third-party administrators.
5. Strong attention to detail and accuracy in data entry and record-keeping.
6. Ability to utilize problem-solving and decision-making techniques.
7. Knowledge of insurance procedures and processes
8. Excellent written and verbal communication and interpersonal skills.
9. Excellent computer skills and proficient in Microsoft Office (EXCEL, VISIO, Word, PowerPoint)
10. Excellent people skills, open to direction and commitment to get the job done.
11. Promotes teamwork, productivity, and delivery of high-quality care.
12. High comfort working in a diverse environment with changing priorities.

CAN Required Trainings:

General Orientation Violence in the Workplace

HIPAA Sexual Harassment

HIV/AIDS Health Stream Courses as assigned

Work Environment:

This job operates in a professional office environment or may be remote. This role routinely uses standard office equipment such as computers, audio visual, telephones, photocopiers, filing cabinets and fax machines.

Position Type/Expected Hours of Work:

This position may require additional time above normal operating hours and on occasion weekend work.

Travel:

When/If necessary, travel is primary during the business day, although some out-of-area and overnight travel may be expected. Must be able to operate a motor vehicle and have valid insurance and driver’s license.

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of an employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

Responsible To: Care Connection Team Manager

CAN Community Health is an equal opportunity employer that is committed to diversity and values the ways in which we are different. All qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.