Authorization Specialist - Business Office Location
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- Authorization Specialist - Business Office Location
Prior Authorizations Specialist
This position is located at our Business Office in Birmingham, AL.
Summary:
Under general supervision, is responsible for obtaining and maintaining prior authorizations for medical services, procedures, treatments, medications, and other services requiring payer approval. Ensures authorization requirements are identified and completed accurately and timely, required clinical and insurance documentation is obtained and submitted, authorization status is monitored, and information is communicated appropriately to the sites and Patient Financial Counselors to prevent delays in patient care and minimize financial risk.
Essential Duties and Responsibilities:
Ensures all prior authorization requirements are identified and addressed accurately and in a timely manner based on the patient's insurance coverage and scheduled services.
Reviews patient, insurance, demographic, and clinical information necessary to determine prior authorization requirements and ensures information is accurately entered and maintained in the system.
Reviews authorization requests received from the sites for completeness and accuracy, noting any missing or inconsistent information and resolving issues by communicating with the appropriate site or clinical staff.
Obtains prior authorizations for services, procedures, treatments, medications, IV/injectable drugs, chemotherapy and supportive therapies, and other services as required by third party payers.
Submits prior authorization requests to insurance companies through payer portals, telephone, fax, or other designated processes, ensuring all required clinical documentation and supporting information is included.
Communicates with insurance companies and payer representatives regarding authorization requirements, clinical criteria, status of pending requests, additional documentation requests, and authorization determinations.
Tracks pending, approved, denied, and expired authorizations and follows up with payers as necessary to ensure requests are processed within required timeframes.
Documents authorization numbers, effective dates, approved services, units or visits, drug or treatment information, payer requirements, and other pertinent authorization details accurately in the appropriate system.
Communicates authorization approvals, denials, pending requests, and significant coverage or authorization issues to the appropriate site, clinical staff, and Patient Financial Counselor in a timely manner.
Identifies authorization-related issues that may result in delays in treatment or potential patient financial liability and immediately communicates those concerns to the appropriate personnel.
Assists with authorization denials and requests for additional information, including coordinating with clinical staff to obtain required documentation and supporting medical necessity information.
Ensures authorization information is updated when there are changes to the patient's insurance, treatment plan, scheduled services, or payer requirements.
Maintains accurate authorization logs, reports, manuals, and other required documentation.
Assists in identifying payer-specific authorization requirements and maintains current reference materials and procedures to support accurate and efficient authorization processing.
Demonstrates an understanding of patient confidentiality in accordance with HIPAA and BHOA guidelines.
Follows policies and procedures to contribute to the efficiency of the front offices and Business Office.
Communicates effectively with physicians, clinical staff, front office personnel, Patient Financial Counselors, insurance companies, and other departments regarding prior authorization matters.
Covers for and assists Patient Financial Counselors and other Business Office personnel with authorizations, intakes, and other functions as requested.
Education and/or Experience:
High School diploma or equivalent. Three (3) years of medical office experience, preferably with prior authorization, insurance procedures, medical billing, referral management, or patient interaction experience.