Job Description

About North Country Healthcare (NCH):

North Country Healthcare is a non-profit affiliation of four medical facilities, Androscoggin Valley Hospital, North Country Home Health & Hospice Agency, Upper Connecticut Valley Hospital, and Weeks Medical Center, located in the White Mountains Region of New Hampshire. NCH includes numerous physicians and medical providers at multiple locations. This leading comprehensive healthcare network which employs hundreds of highly-trained individuals delivers integrated patient care through three community hospitals, specialty clinics, and home health and hospice services. NCH remains committed to the health and well-being of the communities we serve. As a leader in a management position this role emphasizes advancing High-Reliability Organization (HRO) principles, embedding a culture of safety, accountability, and consistent high performance.

The Prior Authorization Specialist plays a crucial role in the healthcare administration process by ensuring that all necessary pre-authorizations for procedures, medications, and services are obtained efficiently. This position involves coordinating between healthcare providers, insurance companies, and patients to facilitate timely access to healthcare while ensuring compliance with all regulatory requirements. The specialist will work in a fast-paced environment and must possess excellent organizational and communication skills to manage a high volume of authorization requests.

ESSENTIAL QUALIFICATIONS

Education:

• High school diploma or equivalent required.Associate’s or higher in healthcare administration, business, or related field preferred.Certification:Certification in Medical Billing and Coding, Certified Medical Administrative Assistant (CMAA), Licensed Nursing Assistant (LNA),or a similar credential is preferred.

Licensure:

• Association* accredited course in Basic Life Support (BLS) (for clinical staff), orHeartsaverCPR AED (for nonclinical staff), and renewal on a regular basis, with up to a three-month grace period after the expiration date.

Skills:

• Strong knowledge of insurance verification processes and medical terminology.
• Proficient in the use of healthcare management software and electronic health records (EHR) systems.
• Excellent verbal and written communication skills.
• Strong analytical abilities and attention to detail.
• Ability to handle confidential information with discretion.
• Proficient in Microsoft Office Suite (Word, Excel, Outlook)

Work Experience:

• Minimum of 2 years’ experience in prior authorization, medical billing, or a related field within a healthcare setting preferredExperience working with insurance companies and understanding various health plans and benefits preferred

ESSENTIAL FUNCTIONS:

• Initiate and process prior authorization requests from healthcare providers for medical services, medications, and procedures.
• Communicate with insurance companies to verify patient benefits, eligibility, and obtain necessary pre-approvals.
• Analyze insurance policies and guidelines to determine requirements for prior authorizations.
• Collaborate with healthcare providers to provide the necessary documentation and information required by payers.
• Follow up on pending authorizations and ensure timely resolution of missing information or denied requests.
• Document and track all authorization requests in the appropriate EHR systems.
• Advocate for patients by ensuring requests are reviewed accurately and efficiently to avoid delays in treatment.
• Provide clear and concise updates to case management staff regarding the status of authorization requests.
• Maintain up-to-date knowledge of payer policies, procedures, and industry trends related to pre-authorization requirements.
• Respond promptly to inquiries from patients, healthcare providers, and insurance companies, ensuring compliance with HIPAA and other regulatory requirements in all communications and documentation.
• Contribute to process improvement initiatives aimed at increasing efficiency and effectiveness of the prior authorization process.
• Assist with training and onboarding new staff as needed.
• Monitor and report on trends related to prior authorization denials and approvals to leadership.
• Assist and support the Employee Health Department with drug screenings as needed.
• Assist and support the Infection Control Department with clerical duties, surgical site letters, lines and drain tracking, scanning, and precautions for rounding.

NON-ESSENTIAL FUNCTIONS

Performs additional duties as assigned.

Adheres to facility Values, Service Excellence, and Standards of Excellence.