Job Description

Job Location: Sheridan Community Hospital - Sheridan, MI 48884Position: Prior Authorization Specialist
Reports To: Revenue Cycle Manager
Schedule: Full time
Position Location/Department: Accounting
Job

Summary:  The prior authorization Specialist will obtain prior authorizations for surgery, swing bed, inpatient/observation stays, emergency services, diagnostic imaging, cardiac imaging, physical therapy, and 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 our patient receives the services needed without delay.

Essential Duties and Responsibilities:
- Receive requests for prior authorizations through the email, electronic health record (EHR) and /or via phone or fax and ensure that they are properly and closely monitored.
- Process referrals and submit medical records to insurance carriers to expedite prior authorization processes.
- Manage correspondence with insurance companies, physicians, specialist and patients as needed, including documenting in the EHR as appropriate.
- Assist with medical necessity review of documentation to expedite approvals and ensure that appropriate follow-up is performed.
- Review accuracy and completeness of information requested and ensure that all supporting documents are present.
- Assist coders/billing staff in the review of denials related to authorizations, and follow up with provider to obtain information for coders/billers to submit an appeal of the denial.
- Prioritize the incoming authorizations by level of urgency to the patient.
- Secure patient information in accordance with policy’s/procedures.
- Participate in quality improvement projects. Attend training and meetings as required
- Maintains awareness of current quality and safety measures on the unit and follows guidelines or reporting measures to ensure safety of patients, visitors, and staff.
- Knowledge and skills in quality improvement and research methodologies.
- Other duties as assigned.

QualificationsEducation, Experience and Other Requirements:
- High School diploma or equivalent
- Previous experience in a hospital and specialty clinic setting preferred
- Previous experience in orthopedic and neurological authorizations preferred
- Knowledge of insurance processes and medical terminology required
- Social and cultural sensitivity appropriate to ethnically and economically diverse patient-and employee-base
- 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 with the organization’s mission
- Be courteous and respectful when interacting with patients and family members
- Maintain patient confidentiality in accordance with organization policies, procedures, and HIPAA requirements