Specialist, Prior Authorization

Job Summary
The Prior Authorization Specialist works with departments and insurance companies to obtain the necessary pre-certifications and authorizations for services ordered/scheduled. Once received these are recorded in Paragon to ensure appropriate billing. The Prior Authorization Specialist maintains a high level of understanding of insurance companies and billing authorization requirements.

Job Requirements
Minimum Education
High school diploma or equivalent
Required SkillsRequires critical thinking skills, decisive judgment and the ability to work with minimal supervision.
Nonessential Functions
other duties as assigned
Essential Functions
Contacts insurance carriers to obtain benefit coverage, policy limitations, authorization/notification, and pre-certifications for identified patients. Follows up with physician offices, financial counselors, patients, and third-party payers to complete the pre-certification process.
Collaborates with Supervisor, internal departments and clinical staff as needed to provide account status updates, coordinate the resolution of issues, and appeal denied authorizations.
Ensures information obtained is complete and accurate, applying acquired knowledge of Medicare, Medicaid, and third-party payer requirements/on-line eligibility systems.
Educates patients, staff and providers regarding referral and authorization requirements, payer coverage, eligibility guidelines, documentation requirements, and insurance related changes or trends.
Ensures all services have prior authorizations and updates patients on their preauthorization status. Coordinates peer to peer review if required by insurance.
Notifies patient accounts staff/patients of insurance coverage lapses, and self-pay patient status. May notify ordering providers if authorization/certification is denied.
May coordinate scheduling of patient appointments, diagnostic and/or specialty appointments, tests and/or procedures.
Maintains files for referral and insurance information and enters referrals into the system.
Maintains knowledge of and reference materials of the following: Medicare, Medicaid and third-party payer requirements, guidelines and policies, insurance plans requiring pre-authorization and a list of current accepted insurance plans.
Serves as an expert for peers across the patient access continuum.
Meets daily productivity and quality standards associated with job requirements.
Performs other job-related responsibilities as requested.