BH Pre-Authorization Specialist

GENERAL SUMMARY:

Demonstrates the ability to verify patient demographics, insurance benefits and obtain prior authorization for scheduled medical services following payer-specific guidelines. Exercises problem resolution skills to assist and direct patients to cultural and community-based resources when necessary.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Assembles information concerning patient's clinical background and presents appropriate and necessary information to payer authorization representatives.

3. *Obtains authorizations for services ordered for all payers (Medicare, Medicaid, and commercial plans) that require authorization.

4. *Works closely with business office team (coders and billers) to ensure accurate procedure and diagnosis codes are being utilized in the pre authorization process.

5. *Completes all requests for authorizations received in a timely manner.

6. *Accurately and completely documents all actions taken regarding the pre authorization process including documenting the pre authorization number/code in the appropriate tracking system (Practice Management).

7. *Remains current with all pre authorization guidelines specific to all payers and informs staff and clinic administration as necessary.

8. *Provides effective communication, proactively and in response, to patients/family members, team members, physicians and other healthcare providers while maintaining confidentiality.

9. Prepares and provides patients with an estimate, if one is warranted, for their expected services and/or connects the patient/guarantor to the estimates team.

10. *Establish and maintain relationships with cultural and community resources relating to assistance with patient experiencing financial difficulty or cost concerns.

11. Attends appropriate workshops to enhance pre authorization skills and payer guidelines.

12. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

13. Participates in meetings, committees and department projects as assigned.

14. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk "*". Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed.

EDUCATION AND EXPERIENCE:

High School diploma or equivalency required. Certified Medical Assistant or Licensed Practical Nurse preferred.Minimum of one (1) year work experience