Prior Authorization Specialist - Remote ID-10055

Full Job Description

Primary Function:

Assists with prior authorizations, appeals and denials.

Update and find current and accurate patient insurance information

Updates authorizations and claims to reflect the new insurance package

Sorts daily work queues and reports to identify and process the daily work

Maintain knowledge in generally accepted insurance benefit terms and processes

Effectively communications as part of the care team (Case and authorization notation - Physician and Practice location staff – Peers - Supervisor/Manager – Payers)

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Requests and prepares supporting documentation such as medical records, dictation, labs, previous prior authorization(s), appeals, denials, and prescriptions

Investigates authorization denials and appeals (Insurance – Patient)

Obtains and reviews clinical notes provided by physicians to assist in filling out prior authorization forms (transcribe verbatim). Submits completed prior authorization via ePA or other methods as necessary

Initiate and obtain appeal required documentation from physicians

Routinely follow up with physicians and insurance companies on the status of the prior authorization, appeal, or denial.

Appropriately moves aspns status to reflect the status of the patients aspn

Rotating shifts during the weekdays between the hours of 8:30 AM to 8:00 PM EST (overtime and occasional weekends as per business requirements).

Job Scope and Major Responsibilities:

Identifies all appointments and procedures for assigned departments that require authorization by monitoring the schedules, system reports, and dashboards

Identifies the referral and authorization requirements of the patients’ insurance plans by using various on-line resources according to department workflows

Demonstrates knowledge of insurance carrier guidelines, clinical policies, and state guidelines pertaining to referrals and prior authorization

Verifies insurance eligibility and benefits, and updates the patient’s insurance information as necessary

Completes referrals and prior authorizations in a timely manner according to department guidelines and workflows

Communicates clearly and effectively with patients, physicians, office staff and manager to resolve issues that may result in a denied or delayed authorization request

Demonstrates complete system knowledge, ability to run reports, document and manage referrals and authorizations, move correspondence, resolve eligibility and authorization holds, and other system tasks within the user’s security access

Demonstrates the ability to request, prepare, and recognize the documentation required to support the medical necessity for the service being authorized

Provides the supervisor and manager with immediate feedback on issues affecting workflow, reimbursement, and customer service

Ensures that appropriate and accurate information is entered in the patient account

Responds timely and collaborates effectively with the ancillary teams to limit denials and ensure proper reimbursement

Collaborates with team members to meet department deadlines and benchmarks

Demonstrates the ability to use the electronic tools and systems available to organize and process the daily work

Anticipates and performs necessary job duties

Maintains patient confidentiality

Maintains professional demeanor and courteous attitude

Compliance with the provisions of the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, as amended (“HIPAA”)

Required Qualifications:

New Jersey Office ONLY:

Certified Pharmacy Technician (must be registered with the State of New Jersey Board of Pharmacy as a Pharmacy Technician)

Arizona Office ONLY:

Pharmacy Technician License (requires national certification by PTCB or ExCPT), or Technician Trainee License, issued by the Arizona State Board of Pharmacy.

ALL LOCATIONS:

Minimum of 2 years pharmacy experience preferred

Previous work experience in a prior authorization role

General knowledge of pharmacy laws, practices, and procedures

General knowledge of what a valid prescription requires

Knowledge of common medical terms/abbreviations and pharmacy calculations

Understanding of insurance and third-party billing systems

Skill to prioritize and work in a fast-paced environment

Exemplary communication, organization, and time management skills

Capability of working independently and as a member of a team

Ability to preserve confidentiality of protected health information (PHI)

Proficient in MS Word, Excel, and Outlook

Possess and maintain professional demeanor and courteous attitude

Experience with standard office equipment (phone, fax, copy machine, scanner, email/voice mail) preferred

Ability to preserve confidentiality of protected health information (PHI)

Capability of working independently and as a member of a team

Prior Authorization Specialist - Remote ID-10055

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