PRE-AUTHORIZATION SPECIALIST

Menomonee Falls, WI - USA

Monthly Salary: Not Disclosed

Posted on: 6 hours ago

Vacancies: 1 Vacancy

Job Summary

Job Description Summary:

Job Summary:
The Pre-Authorization Specialist is a member of the Pre-Authorization Department who is responsible for verifying eligibility obtaining insurance benefits and ensuring pre-certification authorization and referral requirements are met prior to the delivery of inpatient outpatient and ancillary services. This individual determines which patient services have third party payer requirements and is responsible for obtaining the necessary authorizations for care. The Pre-Authorization Specialist provides detailed and timely communication to both payers and clinical partners in order to facilitate compliance with payer contractual requirements and is responsible for documenting the appropriate information in the patients record. Other duties as assigned.

Job Responsibilities:
-Verifies insurance eligibility and benefit levels to ensure adequate coverage for identified services prior to receipt.
-Successfully works with payers via electronic/telephonic and/or fax communications.
-Responsible for verification and investigation of pre-certification authorization and referral requirements for services.
-Coordinates and supplies information to the review organization (payer) including medical information and/or letter of medical necessity for determination of benefits.
-Collaborates with designated clinical contacts regarding encounters that require escalation to peer-to-peer review.
-Communicates with patients clinical partners financial counselors and others as necessary to facilitate authorization process.
-Facilitates submission of clean claims and reduction in payer denials by adhering to both organizational and departmental policies and procedures and maintaining departmental productivity and quality goals.
-Appropriately prioritizes workload to ensure the most urgent cases are handled in a timely manner.
-Completes accurate documentation in both the Auth/Cert and Referral Shells.
-Completes notification to all payers via electronic/fax/telephonic means within 24 business hours of service to ensure compliance with Managed Care contractual requirements.
-Determines Medicare primacy based on Federal guidelines.
-Determines inpatient Medicare coverage for days exhausted and hospice entitlement.
-Ensure timely and accurate insurance authorizations are in place prior to services being rendered.
-Follows departmental policies and procedures when necessary authorization is not obtained prior to service date.
-Answers provider staff and patient questions surrounding insurance authorization requirements.

Skills:

Required Skills & Experience:
-A minimum of two (2) years of experience in hospital billing/pre-authorization or insurance verification with demonstrated knowledge of health insurance plans including: Medicare Medicaid HMOs and PPOs.
-Exceptional customer relations skills.

Preferred Skills & Experience:
-Prior experience in a business office position with strong customer service background.
-Knowledge of online insurance eligibility systems.
-Excellent typing and computer skills.
-Familiarity with Medical Terminology.
-Demonstrated ability to efficiently organize work and maintain a high level of accuracy and productivity.

Required Education:
-High School diploma or equivalent.

Job Description Summary: Job Summary: The Pre-Authorization Specialist is a member of the Pre-Authorization Department who is responsible for verifying eligibility obtaining insurance benefits and ensuring pre-certification authorization and referral requirements are met prior to the delivery of ...

Job Description Summary: