CLINICAL PRIOR AUTH COORDINATOR

3 weeks ago


Littleton NH USA, United States Littleton Hospital Association Full time
Position Summary: The LRH Service Center Clinical Prior Authorization employee will be responsible for functions within the areas of surgical and procedural prior authorizations which may require a higher level of clinical review.

Reports to: Director of Patient Access and Central Services

Essential Functions:
  • Understands the important Littleton Regional Healthcare places on providing exemplary customer service, and performs job functions in a manner that is consistent with LRH processes and organizational customer service goals
  • Responsible for the accurate collection of demographic and financial information in support of claims management, administrative and clinical activities of the hospital.
  • Greets patients in a professional manner through respect and compassion
  • Directs patients to appropriate destinations in the hospital and practices
  • Works with department supervisor/manager on issues related to personal work performance through ongoing education
  • Attends and participates in department staff meetings as requested
  • Adheres to department dress code policies at all times
  • Maintains flexibility in work schedule availability that allows department to change/modify work schedules to meet department needs
  • Meets federal, states and hospital requirements related to compliance issues
  • Demonstrates a positive and professional approach, and communicates effectively with customers and team members at all times.
  • Provide clinical knowledge and act as a clinical resource to non-clinical team staff

Prior Auths:

  • Perform clinical review of authorization requests utilizing appropriate criteria
  • Collaborate with various staff within Littleton Regional Healthcare and the Case Management team to coordinate patient care
  • Identifies all patients requiring pre-certification or pre-authorization at the time services are requested
  • Determines insurance company eligibility and benefits for requested services
  • Follows up with the patient, insurance company, or provider if there are insurance coverage issues in order to obtain financial resolution
  • Performs medical necessity screening as required
  • Obtains necessary clinical documentation from the ordering provider to use in the prior authorization process
  • Evaluates and analyzes that clinical documentation supports the CPT codes and diagnoses listed on orders received in order to meet authorization requirements
  • Effectively communicates clinical information to insurance or prior authorization company in order to obtain authorization and/or certification for requested services
  • Maintains familiarity with insurance carrier prior authorization requirements
  • Partners with members of the Patient Financial Services department

Qualifications:
  • Active NH State Licensure or Certification
  • Minimum of two years in a previous healthcare office setting preferred
  • Strong oral and written communication skills
  • Computer Skills: Knowledge of Microsoft Office
  • Computer Skills: Electronic Medical Records
  • Good spelling and grammar knowledge are essential
  • Basic medical terminology knowledge required

Other:

  • Other duties as assigned

Physical Demands: See physical demands analysis worksheet

Work Environment: Works inside a clean, well-lighted and ventilated area. Works under emergent/stressful situations and may be required to deal with concerned/agitated patients and personnel.

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