Job Description

Summary : The Prior Authorization Specialist reviews insurance information and obtains authorization from patient’s insurance provider to ensure eligibility to receive pediatric therapy services.

Essential Duties and Responsibilities include but are not limited to the following. Other duties may be assigned.

• Handles requests for treatment authorization including out-of-area referrals and verifies member plan eligibility.
• Conducts research on member authorization requests and handles complex carrier inquiries.
• Translating for Spanish speaking patients.
• Interviews and assists patients with authorization documents, as appropriate.
• Reviews Authorization Requests for completeness prior to forwarding to designated person.
• Maintains appropriate logs or reports according to professional, state, and federal requirements.
• Monitors and tracks patient authorizations, informing the Manager of any expired dates.
• Obtains, reviews and inputs insurance authorization prior to patient services.
• Verifies member plan eligibility, with subsequent notification to designated staff of eligibility issues.
• Initiates extensive phone contact with providers, requesting additional information for review based on Prior Authorization requirement protocols where necessary.
• Adheres to the established criteria and timeframes for processing urgent authorization requests.
• Provides effective departmental communication with both internal and external customers.
• Processes member and provider notices in accordance with established timeframes.
• Ensures that any changes made to the authorization request or referral forms have been submitted directly from the requesting provider electronically or by fax.
• Documents all amendments received from providers on the Provider Change Request Form in the designated electronic systems within the established time frame.
• Identifies, maintains and protects sensitive HIPAA information (PHI) and follows procedures to ensure the security of such information.
• Collaborates with Manager, Providers and Medical Billing Staff to resolve problematic Authorization issues.
• Enters data into the Therapy Tree system and notifies the appropriate personnel immediately of problems related to the electronic systems.

Qualifications

• High School Diploma or GED
• Minimum one year of customer service experience
• Minimum one year of healthcare office experience with Prior Authorization
• Bilingual (English and Spanish)

Job Tags

Full time, Immediate start,

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