The Prior Authorization Specialist is responsible for obtaining insurance prior authorizations for Cooley Dickinson Medical Practice patients who have been ordered to have high tech imaging exams performed. The Prior Authorization Specialist works with insurance companies and providers to secure valid prior authorizations that are in place by 2pm the day prior to the patient's appointment. The Prior Authorization Specialist is responsible for researching all updated insurance company plans for authorization policies related to prior authorizations.
ESSENTIAL JOB FUNCTIONS:
Qualifications MINIMUM REQUIREMENTS:
- Validate and secure all necessary prior authorizations utilizing payer websites. Notify the CDH Pre Service department if an authorization is not obtained within the established guidelines for appointment rescheduling.
- Follow insurance guidelines and keep up to date with all insurance requirements and stipulations to obtain reimbursement for services.
- Work productively with all members of the CDH Centralized Scheduling/Central Registration/Pre-Service Team. Accept and contribute to all goals and objectives established by management.
- Utilize computer systems to obtain necessary authorizations, medical necessity, and scheduling options.
- Collaborate with CDMG providers and office staff members to secure any clinical documentation necessary for obtaining prior authorizations. Interact effectively with patients and doctor's offices to gather correct, complete data necessary to ensure that clinical and fiscal responsibilities are facilitated for both the patient and the Hospital.
- Maintain insurance payer authorization and medical necessity requirement grid; distribute to scheduling staff as updated.
- Stay current with new regulations of the many public and private insurance companies which patients carry; such as Medicare, Blue Cross HMO's, Health New England, Tufts, Worker's Comp, and Liability - pre-authorization approval guidelines and medical necessity requirements.
- Provide patient information in accordance with regulations governing divulgence of information (HIPAA). Maintain confidentiality of all patients' records and data. Interface with medical records and billing department as required based on department, hospital, and patient care needs.
- Maintain established hospital and departmental policies and procedures, objectives, confidentiality, patient satisfaction, employee satisfaction, quality improvement program, safety, compliance, and environmental standards.
- Maintain professional growth and development through attendance at seminars, workshops, conferences, or in-services to stay abreast of current trends.
- Meet annual competency and retraining requirements.
- Attend meetings as required.
- Perform other functions/duties as requested.
- High school diploma required; Bachelor's degree in health-related field preferred.
- At least two (2) years of previous experience with obtaining and securing insurance authorizations and full understanding of requirements and processes required.
- Two (2) to three (3) years' work in healthcare environment and in-person customer service experience required.
- Excellent organizational and prioritizing skills with the ability to multitask and the ability to problem solve and work under pressure and under very tight deadlines required; attention to detail required.
- Bilingual in English and another language preferred.
- Strong computer, phone and typing skills as well as Microsoft Word and Excel preferred.
- Familiarity with and understanding of all major health insurers and general coverage issues required.
- Knowledge of third-party payers, insurance regulations, managed care contracting, medical terminology, coding, and clinical considerations required.
- Excellent oral and written communication skills required; the ability to communicate effectively with the public, physicians and all hospital personnel in a high-volume setting required; ability to multi-task required.
It is the policy of Cooley Dickinson Health Care to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, Cooley Dickinson Health Care will provide reasonable accommodations for qualified individuals with disabilities.
Cooley Dickinson Health Care embraces diverse skills, perspectives and ideas, and encourages people of color, veterans, people with disabilities, LGBTQ candidates, and people from other underrepresented groups to apply.