Prior Authorization Specialist - Libertyville, United States - Illinois Bone and Joint Institute LLC

Illinois Bone and Joint Institute LLC

Verified Company

Libertyville, United States

2 weeks ago

Posted by:

Mark Lane

beBee recruiter

Description

:

Summary

Responsible for obtaining prior authorizations for advanced imaging studies including MRI/CT/Bone Scan/Ultrasound/DEXA, Visco supplementation and other specialty drugs/injectables, EMGs, Spine Injections, Outpatient/Inpatient surgical procedures, DME/Orthotics, other miscellaneous Office-based procedures and referral authorizations for some specialist appointments.

Main Objective

Secure the prior authorization and notify the requesting party in the timeliest manner possible to ensure the patient can receive the services needed with the least amount of delay.

Responsibilities

Monitor assigned Epic work queues (WQs) daily. Assign and prioritize the incoming referrals that require evaluation for Prior Authorization by level of urgency to the patient first, then by chronological order.
Adhere to workflow policies and protocols for each service.
Review details of the Referral ensuring CPT codes and ICD10 codes are included and match the documentation for services needed within the medical record.
Communicate with Clinical Teams on any discrepancies within the Referral.
Review Insurance Plan coverage to ensure policy is active prior to initiating the authorization request and Plan requirements for medical criteria are met.
Request, track and obtain prior authorization requests and submit medical records via portal or fax to insurance carriers/medical review companies to expedite.
Utilize payer portals for the Plans that offer/require online Prior Authorization and phone and fax for others.
Manage correspondence with insurance/medical review companies and document all details within the referral and communicate to clinical teams regarding denials or PeertoPeer Requests.
Retain copies of insurance/medical review correspondence within the patient's chart.
Assist with medical necessity documentation to expedite approvals and ensure appropriate followup is performed.
Forward approvals to appropriate departments/staff so patients are contacted to schedule appointments.
Request, track and obtain retro authorization for denied services. Work with the onsite Financial Advisor or Billing/Coding Team Member for difficult account questions that require resolution.
Maintain updates on all Plan's prior authorization and medical necessity guidelines and communicate changes and trends among Team and with appropriate parties.
Safeguard patient information and ensure all information remains confidential.
Maintain a high level of productivity and efficiency.
Crosstrain on related service lines requiring prior authorization and assist coworkers with WQ assignments.
Depending on role, assist in the collection of surgical down payments as needed.
Depending on role, assist patients with questions on coinsurance, deductible and outofpocket expenses.

The job holder must demonstrate competencies applicable to the job position.

Requirements:

Requirements:

High school diploma or GED. Associate degree in business/communication/healthcare field preferred.
Minimum of 2 years administrative / clinical experience in a health care setting.
Knowledge of medical terminology and insurance processes strongly preferred.
Excellent verbal and written communication skills.
Exceptional customer service skills and the ability to maintain professionalism and interact well with patients, staff, and vendors.
Highly computer literate with capability in EHR and PM systems, MS Office, Insurance portals, databases and related business and communication tools and software.
Strong attention to detail and the ability to accurately follow instructions with mínimal oversight.
The ability to exercise independent judgment, decision making, and problem solving.
Strong time management skills. Need to be able to work on tight timelines for last minute addon tests and procedures.
Ability to work effectively in a team environment.

Physical/Mental Demands:

Work may require hand dexterity for office machine operation. This is a desk-based position so there is sitting for extended periods of time. Manual dexterity for using a computer keyboard. Headsets and speaker phones are available.

Environmental/Working Conditions:

Work is performed in an office environment. Involves frequent contact with staff, patients, and the public. Work may be fast paced and stressful at times.