The Lead Prior Authorization Specialist position leads, organizes, and oversees the Prior Authorization Specialist teams whose primary function is to provide premier customer service to the patient, physician and office staff by obtaining facility authorizations for patients scheduled at SPH. The Lead and team are required to verify insurance coverage and obtain insurance authorizations. The Lead and team is required to maintain a working knowledge of all Managed Care Contracts as well as insurance requirements and policies for authorizations, notifications and/or referrals. The Lead ensures the team utilizes the system functionality as well as office equipment such as a scanner, credit card terminals and fax machine. The Lead will also ensure the team is in communication with outside physician offices and ancillary departments within the hospital to complete an accurate patient record. 

 

KNOWLEDGE/EXPERIENCE:  

Intermediate knowledge of ICD-10-CM and CPT coding guidelines.  Intermediate knowledge of anatomy and physiology, medical terminology and disease processes.   Intermediate knowledge of payer guidelines and policies, documentation requirements, and authorization process.  Cognitive, organizational and emotional abilities to deal effectively with multiple stressors, deadlines and customer needs. Excellent organization, time management and prioritization skills required.

EDUCATION: 

High school diploma, HiSET or GED equivalent required.  Successful completion of advanced healthcare course work preferred.  Approximately three to five years’ work experience in prior authorization preferred.  Completes Patient Financial Services I, II, and III training levels and Prior Authorization Certified Specialist training.

Aptitudes: 

Ability to achieve cognitive, organization and emotional maturity to deal effectively with multiple tasks, stresses, deadlines, difficult situations and/or customers.  Possesses interpersonal/communication skills necessary for effective, non-judgmental, and empathetic customer relations. Open to feedback and open to a changing environment, which requires flexibility in scheduling and department assignments. Create, maintain, and promote a respectful work environment consistent with SPH patient and employee satisfaction culture. Ability to make decisions and trouble shoot using various resources available.  Attention to detail and accuracy. Ability to accurately and efficiently document customer interactions. Possess a customer-focused mindset. Regular and predictable attendance.

 

Fosters an environment of teamwork, communication, and service excellence within the team and department. Works collaboratively with staff and departments to provide premier customer service to the patient, provider and office staff.  Ensures proper staffing and distribution of assignments and workload.  Reviews and works to enhance workflow, processes and workloads in prior authorization department to obtain authorizations in a timely, effective and accurate manner, and to ensure balance and optimization in meeting targets and goals.  Responsible for reporting and working with leadership, staff and departments to manage and meet department and individual goals related to productivity, completion days, authorization accuracy, and addressing denials or issues timely and effective, and other areas as needed and defined. Develop and maintain prior authorization team training and education plan and program, to include coaching and training on processing techniques, documentation requirements, written and/or electronic resources, payer update and education opportunities, regulatory and policy updates, etc.  Works closely with staff and departments to develop an effective and efficient denials management program. Assists in implementing solutions to reduce prior authorization errors so claims are accurate before submitted. Resolves denied claims due to prior authorization issues with team.  Researches, identifies and works to resolve root cause issues causing authorization and denials issues related to prior authorization process. Adheres to policies and procedures to monitor the success of the department, review areas of risk, investigate identified issues, and take appropriate steps to correct issues.    Adapts and learns new tasks as required and demonstrates a willingness to work where needed. Mentors, coaches, trains team unit.  Super user for current and future computer functionality used in assigned area. Maintains relationships with external partners and payers. Explores opportunities to improve relationships. Understands, promotes and holds team accountable for department goals. Assists/participates in leadership duties to start developing leadership knowledge and skills.  Performs other duties and coverage as assigned and/or needed.