Prior Authorization Specialist

Prior Authorization Specialist

The Authorization Coordinator is responsible for obtaining appropriate insurance pre-certification/preauthorization prior to the provision of scheduled Infusion Center services or treatments. This is an on-site position, which allows for direct in person communication with patients, staff and providers. He/she is accountable for pre-registering patients in Meditech, verifying insurance eligibility and obtaining authorization as needed from the payer, Additionally, he/she will be the primary on-site liaison in the Infusion Center for referring providers' offices, patient access staff, insurance carriers, as well as patients and other hospital staff regarding insurance pre-certification/preauthorization verification. This position requires strong computer, interpersonal and communication and organizational skills, as well as knowledge of 3 rd -party insurance pre-certification/preauthorization policies and procedures. At least 2 years of CPT / HCPCS and ICD-10 coding experience and medical terminology is required. Knowledge of IV drug administration coding and billing is a plus.

1. Reviews referring physician orders and documentation received for medical necessity against specific
insurance protocol requirements for authorization purposes.
2. Proactively reviews infusion schedule in advance and pre-registers patient, obtains insurance verification
and/or authorizations for insurance approval for scheduled and urgent infusion services. Documents all
authorizations in Meditech.
3. Communicates to Infusion Center staff and SH pharmacy regarding individual patient plan payer requirements
for drugs to be supplied by payer specialty pharmacy for specific patient treatments to assist with tracking
shipments and receipt of drug prior to treatment.
4. Actively communicates with Infusion Center and patient access staff throughout the workday regarding status
of pending authorization for scheduled services prior to appointment date (e.g.., communicate need for
reschedule and/or cancellation if authorization not received).
5. Actively receives updates from Infusion Center staff throughout the workday regarding any changes to
existing treatment orders or appointment dates (based on established protocols) and reviews current
authorization to ensure authorization is still valid. Obtains new authorization as needed. Documents all updates
and new authorizations in Meditech.
6. Acts as a direct liaison with referring provider's offices and patients regarding new, changed, or pending
insurance authorizations, as well as on-going education of changes in authorization requirements. Requests
additional documentation as needed from referring provider offices for authorization.
7. Arranges peer-to-peer reviews as needed for authorization with payer and referring provider.

8. Participates in development of on-going process improvements related to insurance verification, pre-
registration, and authorization management processes.
9. Routinely interacts with patients, their representatives, physicians, physician office staff, and others to gather
and ensure accuracy of demographic, billing, and clinical information, consistently demonstrating
professionalism and respect.
10. Attends scheduled staff meetings, in service education opportunities, and participates in continuing education
programs. Creates and maintains effective working relationships with employees and staff in the infusion
center, pharmacy, other hospital departments and physician offices.
11. Respects and protects the patient's rights to confidentiality and privacy and discloses information only for the
professional purposes which are in the patient's best interests with full consideration of their legal rights.

Requirements:

• High School Graduate or equivalent
• At least 2 years medical coding and/or billing background
• Good PC skills, especially Microsoft Outlook, Word, and Excel.
• Ability to effectively multi-task and learn/ adapt to new systems and technology
• Demonstrates patience, professionalism, and respect consistently with patients, providers, and staff.
• Is dependable, punctual, and works with a high degree of integrity and accountability.
• Provides high-quality customer service at all times.
• Performs other related duties as assigned or requested in order to maintain a high level of service.
• Accepts direction and constructive criticism and responds appropriately.
• Effectively works as a member or a care team, and communicates effectively with co-workers, supervisors and management regarding any issues or concerns.
• Complies with departmental and organizational policies and procedures.
• Completes required continuous training and education, including department specific requirements.
• Must be able to articulate well in English and possess excellent written and verbal communication skills.
• Bi-lingual a plus