JOB SUMMARY

Under the guidance of the Manager of Patient Access and Director of Revenue Cycle, the Prior Approval Specialist will oversee the process of collecting all necessary documentation needed for approval of hospital diagnostic testing, outpatient procedures, surgery, injections, medication needs and any other requirements needed to help assist the Revenue Cycle in correct reimbursement. They will help guide all departments of the hospital on all requirements for services in regard to prior authorizations. Will exhibit excellent customer service skills, and effective communication skills. Will be responsible for maintaining education, and assisting with communicating new changes. Will be able to preform all aspects of the job.

Always strives for superior performance by consistently providing a product or service to leadership and staff that is recognized as ultimately contributing to the patient and family experience. Recognizes and demonstrates understanding of patient and family centered care.

PRIMARY JOB RESPONSIBILITIES

1. Verifies patient’s insurance benefits, eligibility, and network status.
2. Ability to submit insurance authorizations, understanding the payer’s requirements and time lines.
3. Can relay the Peer-to-Peer process to the provider with an explanation of what is needed.
4. Ability to reach out to the Provider for additional documentation, update medication needs and ability to review the chart.
5. Understands CPT codes and ICD-10 codes.
6. Tracks patients referrals with the verification of diagnosis code, and procedure to be sure that this reimbursable by the payer.
7. Participates in and offers training programs and educational activities as indicated.
8. Communicates well with all team members as needed to keep up to date on patients care.
9. Remains well versed in all computer applications pertinent to job duties.
10. Completes work within authorized time to assure compliance with department standards and payer requirements.
11. Demonstrates flexibility in response to unexpected changes in patient volumes, staffing and scheduling needs.
12. Maintains confidentiality of all information.
13. Maintains a well-organized environment to work at maximum efficiency.
14. Willingness to cross train within the department to effectively assist and understand other job functions as needed.
15. Maintain Productivity standards and time frame guidelines.
16. Demonstrates knowledge of and supports hospital mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality statements, corporate compliance plan, customer service standards, and the code of ethical behavior.

DEPARTMENTAL AND ADDITIONAL JOB RESPONSIBILITIES

1. Special Projects as assigned by Manager of Patient Access or Director of Revenue Cycle
2. Other duties as assigned

JOB SPECIFICATIONS

EDUCATION (List required, and preferred if applicable)

1. High School diploma/ GED required. Associate degree preferred.
2. Medical Terminology preferred.
3. Post high school courses in coding, health insurance and or office procedures preferred.
4. Ability to navigate a patients chart within the EMR.
5. Previous experience with Prior Authorizations preferred.
6. Medical Assistant certification preferred.
7. Experience with Oncology, Pharmacy or Physician office preferred.

EXPERIENCE (List required, and preferred if applicable)

1. Minimum one years’ pre certification experience preferred, particularly for CPT, HCPC and ICD-10 codes
2. Excellent phone and customer service skills.
3. Knowledge of Health insurance plans including benefits, and authorizations.
4. Ability to effectively listen and solves problems quickly.
5. Ability to navigate a patient’s chart within the EMR.
6. Previous experience with Prior Authorizations preferred.
7. Medical Assistant certification preferred.
8. Experience with Oncology, Pharmacy or Physician office preferred.

ESSENTIAL PHYSICAL ABILITIES/MOTOR SKILLS

1. Able to travel independently throughout all Memorial Healthcare facilities.
2. Small motor skills required for operating modern computer, office, and telephone equipment as utilized by Memorial Healthcare (MHC).
3. Ability to sit or stand for long periods of time.

ESSENTIAL TECHNICAL ABILITIES

1. Proficiency using modern office, computer and telephone equipment as used by Memorial Healthcare.
2. Ability to entre and retrieve data from computers.
3. Ability to pull reports and understand the data.

ESSENTIAL MENTAL ABILITIES

1. Ability to adapt and maintain focus in fast paced, quickly changing or stressful situations.
2. Ability to read and interpret a variety of documents including, but not limited to policies, operating instructions, white papers, regulations, rules and laws.
3. Ability to ask for money, explain insurance benefits as it pertains to each departments job functions.

ESSENTIAL SENSORY REQUIREMENTS

1. Able to see for the purpose of reading information received in formats including but not limited to paper, computer, reports, bulletins, updates, manuals.
2. Able to hear for work-related purposes.
3. Ability to communicate receptively and expressively both written and spoken.
4. Ability to maintain self-control.
5. Ability to direct phone calls or requests effectively if answer is not known.

INTERPERSONAL SKILLS

1. Ability to interact with co-workers, hospital staff, administration, patients, physicians, the public and all internal and external customers in a professional and effective, courteous and tactful manner, at all times, physically, verbally and in all written and electronic communication.
2. Required to remain calm when adversity is encountered.
3. Open, honest, and tactful communication skills.
4. Ability to work as a team member in all activities.
5. Positive, cooperative and motivated attitude.