GENERAL SUMMARY:

Reviews all procedures, referrals and prescription medications with the applicable insurance policies to ensure all the payer's required guidelines are met prior to the service being rendered to ensure maximum reimbursement. Responsible for communication with all offices and appropriate personnel regarding the authorization of services. Responsible for any required retro-authorizations as well as communicating any peer-to-peer review requirements between the payer and the ordering provider or assigned advanced physician provider.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs of Bryan Health and consistently demonstrates our core values.

2. *Serves as work resource and liaison to hospital departments, physician offices and patients for pre-service authorization.

3. *Adheres to federal regulations regarding Advance Directives, COBRA, Medicare, Corporate Compliance, Joint Commission, OSHA and HIPAA; reports safety and customer concerns.

4. Maintains productivity and quality standards as defined through the organizational and departmental goals and objectives.

5. Serves as work resource and liaison to internal and external hospital departments, physicians’ offices and patients for pre-service authorizations.

6. Submits patients supporting medical records and necessary information to payer authorization representatives for prior authorizations via fax, phone or online portals.

7. Submits prior-authorization request for prescription medications using online portals, fax or phone along with supporting medical records.

8. *Accurately and completely documents all actions taken regarding the prior authorization process including the authorization numbers, authorized dates and all other applicable information in the applicable computer systems

9. *Ensures that pre-certification and/or authorization and referral requirements have been completed by placing phone calls to insurance companies, physician offices, patients, and utilizing web based applications and/or internet resources; obtains clinical information from physician offices and/or Bryan system; contacts Clinic coding staff to obtain CPT and/or ICD-9 codes.

10. *Explains notice of non-coverage or offers to re-schedule elective tests and procedures when patient’s pre-authorization is not obtained; notifies patient and physician of outcome; Provides effective communication, proactively and in response, to patients/family members, team members, physicians and other healthcare providers while maintaining confidentiality.

11. *Coordinates obtaining waiver of liability when third party payers deny coverage or services that are non-covered.

12. *Prepares and provides patients with an estimate, if one is warranted, for their expected services and/or connect the patient/guarantor to the estimates team.

13. Maintains accurate payer website information and logins to ensure most current information is obtained for the necessary authorization requirements.

14. Communicates with Patient Financial Services regarding denials and appeals/reconsideration letters received from payers.

15. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

16. Participates in meetings, committees and department projects as assigned.

17. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk “*”. Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed.

EDUCATION AND EXPERIENCE:

High School diploma and one (1) year relevant work experience in a medical clinic, health care, insurance industry, pharmacy or medical billing office required. Certified Medical Assistant or Medication Aide, coding certificate or other clinical background preferred. Must be 19 years of age to witness legal consents