AUTHORIZATION SPEC II
US-WA-Wenatchee
External
Req #: 13767
Type: Full-Time
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Overview: The Outpatient Authorizations Specialist - Certified is responsible for determining when an authorization is required for healthcare services and for submitting prior authorization requests in accordance with health plan requirements. Documents all authorization information and determinations in the patient's electronic medical record. Proper execution of this work directly impacts revenue for the organization and supports its denial management and prevention strategies. Position Reports To: Authorizations Manager Responsibilities: * Researches prior authorization requirements and submits prior authorization requests in a timely manner. * Researches, recognizes, requests, and submits the clinical documentation required to support the medical necessity of the service being authorized. * Properly documents all authorization requests and decisions in the patient's auth/cert or referral record utilizing standard EPIC workflows and work queues. * Accurately interprets medical policies and how they pertain to services being authorized. * Utilizes payor tools and websites as needed to facilitate prior authorization requests. * Verifies insurance eligibility and benefits and updates patient insurance information as needed. * Reviews and resolves all reported authorization issues. * Proactively researches and stays informed of changing insurance pre-authorization requirements and health plan updates. * Communicates with providers, Staff, and Patients to keep them apprised of the status of the authorization requests and processes denied authorizations in a timely manner. * Keeps pace with workflow by remaining up to date on work and preventing backlog in workflows. * Collaborates with teammates and leadership to identify process improvements and optimizations. * Advises leadership of payor trends and issues. * Develops and maintains positive rapport with both internal and external customers. * Participates in team huddles, meetings, and trainings as required by leadership to maintain collaboration, continuing education, and team synergy. * Collaborate with other SME's, Outpatient Authorizations Lead and the Outpatient Authorization Manager to establish best practice standards. * Continually improve work process to enhance service and customer relations. * Investigate authorization denials and assists with appeals. * Troubleshoot escalated requests from staff and providers and problem solves for difficult and unusual authorizations and referrals. Assists in problem identification, quantification, and resolution. * Provide education and communication to providers and staff regarding prior authorization requirements by payor and procedure/service. Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times. Qualifications: Required: * High School Graduate or equivalent. * Minimum 2 years working in a healthcare setting as an Authorization Specialist and/or a certification/credential in one of the following: * AAHAM - CRCS * AAPC - CPC * MA-C * Demonstrated experience with insurance requirements for referrals and/or prior authorizations to various therapies, surgeries, procedures, diagnostic testing, etc. * Possesses intermediate computer skills (e.g., spreadsheets, word processing); knowledge of MS Office * Effective written and verbal communication skills. * Effective reading comprehension skills. * Demonstrated customer service experience in an office or clinical setting * Ability to multi-task and thrive in a dynamic and fast-paced environment * Experience investigating denials. * Ability to prioritize workload and meet deadlines while being flexible to the changing demands of coverage. * EHR proficiency. Desired: * Associates degree. * Experience in CPT/ICD-10 coding. * EPIC experience in Prelude, Cadence, Grand Central, and/or Resolute applications.
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