Prior Authorization Specialist

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that's served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It's our passion.

Summary

Responsible for performing benefits verification and prior authorization functions with insurance carriers to ensure optimal reimbursement for high cost medications, surgeries and procedures, within an established time frame, for patient cases submitted to Patient Financial Services.

Responsibilities

1. Ensures correct referral form is completed for patients plan. Reviews referral for accurate information prior to authorization to include patient provider identification information, clinic or procedure requested, and appropriate CPT-4 /billing codes. Contacts clinic to obtain additional information as needed.

2. Assists with medical necessity documentation and clearance to expedite approvals and ensure that appropriate follow-up is performed.

3. Collaborates with other departments, clinics, and procedures areas to assist in obtaining authorization/pre-certifications in a cross functional manner.

4. Contacts plans to extend authorization dates, obtain additional visits and urgent/priority authorizations/pre-certifications, as needed.

5. Notifies clinic/procedure area, Nurse Navigator, Providers and/or patients to inform them of the authorization denials. Obtains additional clinical information for denials and submits appeals to the plan for further consideration.

6. Completes documentation of referrals in software to include the authorization number, number of visits, and the authorization period (dates) to ensure claims are paid in a timely manner.

7. Utilizes software to process and track referrals and submit medical records to insurance carriers to expedite prior authorization processes.

8. Creates patients records and accounts and ensure that pre-authorization information is properly updated.

9. Secures patients demographics and medical information and ensures that all procedures are in sync with HIPPA compliance and regulation.

Other duties as assigned.

Career Type: Support

Individual contributors who support operational, functional or business strategy through tactical support of daily activities (clerical, administrative, technical). The majority of time is spent in the delivery of front line services or activities, typically under direct supervision.

Works to deliver day-to-day objectives with impact typically limited to particular job area and/or department

Makes minor adjustments to work methods to solve problems that are often routine and typically exist in current work processes and systems. Changes often require higher-level approval

Requires knowledge of operational, functional, and/or business systems and practices

Competencies

Leadership & Talent Management

• May provide guidance, helping to train and review work of entry level employees

Organizational Impact

• Delivers on day-to-day objectives with direct impact on team/unit results with some supervision
• Daily challenges are typically of a routine nature, but may at times require interpretation or deviation from standard procedures

Communication & Influence

• Communicates information that requires explanation or interpretation of moderate importance to the team/unit

Knowledge & Experience

• Requires broad knowledge of operational, functional, and/or business systems and practices, typically obtained through some experience, education, or vocational training

Degree

• No advanced education is typically required

Years of Experience

• >3 and <6 Requirements

Education Requirements

HS/GED High School Diploma or GED.

Preferred

None

Required Certifications / Licensure

None Preferred Certifications / Licensure

None

Equivalent Education and/or Experience

None

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.As part of our commitment to our patients and employees' wellness, Parkland Health is a tobacco and smoke-free campus.