Pre-Authorization Specialist I

Overview

At Augusta Health your work matters and so do you. Whether youre delivering direct patient care supporting operations or innovating behind the scenes every role contributes to our mission of promoting wellness and healing through compassionate service. We offer more than just a job we offer a purpose-driven career in a nationally recognized independent health system located in Virginias scenic Shenandoah Valley.

Learn more about career opportunities on our Careers Page.

Our team members thrive in a supportive culture that values collaboration integrity and excellence. With opportunities across clinical and non-clinical areas Augusta Health is a place where your skills make a difference and your growth is a priority.

Why Join Augusta Health

We believe in taking care of the people who care for our community. Thats why Augusta Health offers a comprehensive and thoughtfully designed benefits package that supports your well-being career development and work-life balance. Whether youre launching your career or bringing in years of experience we provide the tools resources and encouragement to help empower you to reach your full potential personally professionally and financially.

Explore our Benefits current Hiring Incentives and our Taking Care of Us initiative which embraces Belonging Respect Inclusion Diversity Growth and Equity (B.R.I.D.G.E.) to see how we invest in our team members and culture.

Total Rewards & Benefits (may vary by position)

• Comprehensive insurance package including medical dental and vision coverage
• Retirement savings plans and financial wellness support programs
• Generous paid time off and flexible scheduling to promote work-life balance
• Career development programs including clinical ladders shared governance and advancement opportunities
• Personalized onboarding with dedicated preceptors and ongoing educational support
• Tuition reimbursement and access to onsite childcare
• Free onsite parking 24/7-armed security for your safety a Health Fitness Reimbursement Program and an onsite credit union and pharmacy
• Competitive pay with shift/weekend differentials
• Employee discounts at the cafeteria gift shop pharmacy and local entertainment venues (i.e. movie tickets)

Full details are available on our Benefits Page.

Job Summary

The Pre-Authorization Specialist is an essential role responsible for facilitating exceptional patient experience by securing authorizations for all scheduled services related to medical and surgical admissions across entities. This is a role that is critical to the organizations financial health. The duties consist of obtaining pre-authorizations for at least one modality in outpatient medical imaging outpatient surgeries special procedures Heart & Vascular Interventional Radiology Pain
Management OB Services scheduled admissions or genetic lab testing. The position requires the ability to independently plan schedule and organize numerous tasks as this position directly impacts hospital and physician reimbursement.

This position plays a critical role in supporting Augusta Healths mission and advancing departmental goals through measurable performance indicators and service excellence. This position contributes to a collaborative patient-centered environment and helps drive outcomes aligned with organizational priorities.

Essential Job Duties

• Generates and monitors worklists to ensure all scheduled appointments are properly reviewed and pre-authorizations secured in accordance to standard and expectation.
• Verifies insurance coverage collecting and documenting insurance benefits and authorization requirements and procuring necessary authorizations for medical services and outpatient services according to patient insurance protocols using available tools and insurance portals.
• Acts as a subject matter expert in insurance benefits and authorization requirements.
• Obtains pre-certification for scheduled inpatient admissions electronically via insurance portals or telephone. Ensures that authorizations for outpatient surgeries special procedures outpatient Medical Imaging Outpatient Surgery Special Procedures H&V Cath Lab Interventional Radiology Pain Management and other services as assigned are obtained per timeline protocols. Documents and scans insurance authorization information in the appropriate fields within the computer system.
• Verifies all of the components of the authorization are correct including the facility provider CPT code admission type NPI TIN and effective dates.
• Accesses analyzes and selects relevant patient clinical information based on procedure codes (CPT) and diagnosis codes (ICD-10) to submit to insurance companies to support pre-authorization requests.
• Works closely with Financial Advocates and/or Patient Access leaders to offer financial options such as upfront payment payment plans MDSave and/or financial assistance for patients who do not have insurance coverage or who had pre-authorizations denied by their insurance carriers.
• Reports denials and pending authorizations for scheduled services to management to determine proper plan of action.
• Obtains retro authorizations for services updates patient accounts with the retro authorization information and communicates with the Billing Department to have claims submitted to insurance companies for reprocessing.
• Provides regular feedback to management related to payer issues provider office issues and any other issues that will delay obtaining authorization
• Contacts insurance companies managed care plans outside agencies and intermediaries to verify insurance coverage and benefits. Determines if any pre-admission/pre-visit requirements exist e.g. predetermination of medical necessity need for out of network plan auth required in addition to the service/procedural auth etc.
• Ability to identify incomplete clinical documentation that is needed to obtain approval for services. Interacts directly with physicians/clinicians/physicians office staff via Athena phone calls and Outlook to identify what is missing and to collect further complete and appropriate patient data and clinical information necessary to submit to Medical Insurance to review for authorization of services scheduled.
• Monitors pending cases to ensure that approvals are obtained prior to admission or visit.
• Informs doctors office of any additional clinical requested including notes that are lacking tried and true therapies/refrainment e.g. Imaging Orthopedic or Neuro Spine cases.
• Assists reimbursement team in authorization related corrections on rejected or denied claims.
• Obtain retro authorizations on billed and rejected claims and denied procedure codes for facility. Initiate appropriate follow-up actions in response to information obtained and document outcomes for appeals as needed.
• All other duties as assigned

Required Qualifications

• Education: High School Diploma or GED equivalent
• Licensure/Certification: None
• Experience: 1-year previous experience in patient/customer-facing role
• Drivers License: N/A
• Eligibility to work in the United States and meet Virginia state employment requirements

Preferred Qualifications

• Education: Associates degree
• Licensure/Certification:
  • CHAA certification with the National Association of Healthcare Access Management (NAHAM) can be obtained on the job.
  • AAPC Medical Coding Certification
• Experience:
  • Knowledge of CPT and ICD-10 coding
  • Medical Terminology
  • Previous experience in hospital healthcare practice or health insurance company Pre-authorization Specialist Insurance Specialist or similar
• Prior experience in a hospital healthcare system or related service-oriented environment
• Familiarity with Augusta Healths systems workflows or organizational culture is a plus

Competencies Knowledge Skills and Abilities

• Good interpersonal communication skills and positive attitude
• Organization prioritization and problem-solving skills
• Self-starter ability to work with minimal supervision
• Adaptable to change
• Experience and competent in customer relation skills in a professional environment
• Experience in Microsoft Office products
• The individual must exhibit effectiveness as a member of a team and be self-directed
• Articulates knowledge and understanding of organizational policies procedures and systems
• Ability to effectively work in a remote environment and connect via multiple communication channels (phone email text etc.)
• Clearly and thoroughly document all actions contacts outcomes and interventions
• This position requires basic knowledge of insurance requirements and good computer skills

About Augusta Health

Augusta Health is an independent nonprofit mission-driven health system located in Fishersville Virginia in the heart of the Shenandoah Valley. We offer a full continuum of inpatient and outpatient services including Augusta Medical Centera 255-bed facilityand Augusta Medical Group which operates 40 practice locations and four urgent care centers. Our commitment to excellence innovation and compassionate care makes Augusta Health a leading employer and healthcare provider in the region.

Discover more about our history values and community impact on our About Us Page.

Equal Opportunity Statement

Augusta Health recruits hires and promotes qualified candidates for employment without regard to age color disability gender identity or expression marital status national or ethnic origin political affiliation race religion sex (including pregnancy) sexual orientation veteran or military discharge status and family medical or genetic information.

We are committed to fostering a diverse and inclusive workplace in accordance with federal and Virginia state employment laws.

Required Experience:

IC