Suite 1001 MOC
Summary This position is responsible for ensuring appropriate prior authorization for designated specialty. The scope of prior authorizations may include (but is not limited to) consults, diagnostic testing in office procedures and pharmaceuticals including off label drugs, and drugs for clinical trials. The Authorization Specialists will perform all job functions in a courteous and professional manner consistent with the mission and core values of St Peter’s Health Partners Medical Associates. Job Duties • Submit and obtain authorization requests for service line. • Maintain subject matter expertise on authorization requirements by payer and order type to ensure proper authorization obtained pre-procedure. • Review authorization denial trends in partnership with supervisor to identify and address gap areas leading to auth denials within service line. • Confirm appropriate insurance verification as part of auth obtainment responsibilities. • Obtain retro authorizations when necessary. Responsibilities • Obtain and track authorizations/re-authorizations for both new and existing patients in accordance with their insurance policies while following all federal, state, and local medical policy guidelines. • Initiate Peer to Peer’s with payer while working closely with providers and clinical staff to obtain letters of Medical Necessity to support reimbursement. • Monitors all authorization work queue for pending or expiring authorizations. • Scans in approval letters after verifying for accuracy. Authorizations Specialist I Job Description Updated 06-25-18 • Contact the insurance company to check status of authorization submission in a timely manner. • Troubleshoot authorization denials in efforts to overturn payer behavior related denials. This description is intended to only provide basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve. These responsibilities are subject to change at any time. Qualifications ➢ High School graduate, Associates Degree preferred. ➢ Preferred certification in CCS, CCS-P, CPC, or specialty coding. ➢ One to three years’ experience in a health care environment with exposure, preferably to service line of position with knowledge of the patient population and types of services patients receiving. Prior authorization experience involving service line drugs and ancillary testing desirable. ➢ A strong understanding of HIPAA laws and requirements as they relate to review and ➢ reporting of documentation. ➢ Knowledge of managed care and third-party payer benefits designs and reimbursement ➢ requirements. ➢ Knowledge of ICD-9 and ICD-10 coding and documentation requirements. ➢ Proficient in Microsoft Office applications including Outlook, Word, and Excel. Preferred experience in EPIC or comparable EMR system ➢ Strong analytical skills with attention to detail and high degree of accuracy in order to ➢ produce reports, analyses, and other detail as requested ➢ Strong communication skills. Attention to detail. Knowledge of drug regimens and associated regulations/policies/procedures applicable to insurance coverage and the associated payment for and appeal of procedures/billing rejected. ➢ Two years of experience in reviewing medical records for National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) ➢ Demonstrated experience with delivering successful customer service ➢ Demonstrated experience with handling multiple priorities in a deadline driven environment. ➢ Remaining calm under pressure and adaptable with changing priorities ➢ Managing difficult customers respectfully and without confrontation ➢ Previous medical office experience preferred
Pay Range $19.50-$27.85
Pay Range based on Location and Experience
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.