Job Description

Job Location: 222 22ND AVE NORTH - NASHVILLE, TN 37203, Job Summary

The Prior Authorization Specialist will obtain prior authorizations as determined by the specialty or specialties assigned to the position. Examples of prior authorizations include but are not limited to diagnostic imaging, cardiac imaging, prescription medications including IV infusions, and referral authorizations for some specialist appointments. This position will secure the prior authorization and notify the rendering party in the timeliest manner possible, so a patient receives the services needed with the least delay.

Responsibilities (include, but are not limited to)

• Reviews requests for prior authorizations through the electronic health record (EHR), phone and/or fax per department workflow and ensures the request is properly and closely monitored
• Confirms patient benefits and process referrals to insurance carriers
• Serves as point of contact to patients for any financial patient responsibility questions and directs patients to a billing representative for any explanation of benefits or billing questions
• Manages correspondence with insurance companies, physicians, providers, practice staff and patients as needed, including documenting in PM and the EHR authorization details including status, relevant dates, etc.
• Assists with medical necessity documentation to expedite approvals and ensures that appropriate follow-up is performed.
• Reviews accuracy and completeness of information requested and ensures that all supporting documents are present.
• Reviews denials and follows up with practice staff to obtain medically necessary information to submit an appeal of the denial
• Notifies practice staff if a peer-to-peer review is required and escalates to manager if necessary
• Prioritizes authorizations deemed timely by the physician or practitioner
• Secures patient information in accordance with organizational policies and procedures
• Communicates expectations of other role types as it relates to a prior authorizations (e.g., notifies front office staff of required co-pay or deductible at the time of service, notifies practice staff of authorization status and scheduling next steps)

SUPERVISORY RESPONSIBILITES

• This job has no supervisory responsibilities

Qualifications: Knowledge, Skills, and Abilities

• Communicates through appropriate channels. Use proper chain of command for patient complaints.
• Ability to handle emergency situations calmly and effectively.
• Must be computer literate and able to navigate through the Electronic Health Record.
• Must be able to maintain good inter-personal relationship with co-workers and other members of the health care team and the organization.
• Provide customer service in accordance to the organization’s mission.
• Be courteous and respectful when interacting with patients and family members.
• Maintain patient confidentiality in accordance to organization’s policy and procedure and HIPAA requirements.

Job Requirements

• High school diploma or equivalent.
• Previous experience in a clinic setting preferred.
• Knowledge of insurance process and medical terminology preferred.

Physical Demands and Work Environment

• Sedentary work, must be able to sit for 8 to 10 hours a day
• Must be able to push/pull up to 25 lbs.
• Ability to delineate between numeric numbers
• Repetitive motion, substantial movements (motions) of the wrists, hands, and/or fingers. The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading
• Office environment-limited exposure to communicable diseases
• No exposure to blood-borne pathogens or contaminated body fluids