Prior Authorization Specialist

3 weeks ago

Appleton, United States Neuroscience Group Full time
Job DescriptionJob DescriptionDescription:

Neuroscience Group of Northeast Wisconsin S.C. has an immediate opening for a full time Prior Authorization Specialist. This position will work Monday - Friday 8 hours per day. As an integral member of the Clinical Services Team, the Prior Authorization Specialist is responsible for pre-authorizing ancillary testing and treatment conducted in the Neuroscience Group office and outside the office setting. This position includes verification of insurance benefits as it applies to the precertification process and obtaining precertification/preauthorization from payors.


For over thirty years, Neuroscience Group has provided excellent neurologic care for the Fox Valley and Northeast Wisconsin. Ours is the only medical facility in the area that combines neurosurgery, neurology, orthopedic spine surgery, interventional and non-interventional pain management and physical therapy. Our practice has grown to over 50 providers and serves patients in nine outlying clinics scattered throughout the region. Our mission is to improve lives by providing the very best in brain, spine and pain care and we do that by living our company core values: compassionate care, teamwork, fiscal responsibility, continuous learning, leadership and community involvement.


RESPONSIBILITIES:

  • Collects and verifies all patient insurance information; makes changes/updates to information as needed.
  • Upon receiving the anticipated procedure codes and orders from the practitioner; reviews clinical documentation for medical criteria/guidelines as identified by the insurance companies.
  • Reviews CPT and Diagnosis codes for each order for accuracy before submitting to insurance.
  • Reviews patient chart documentation, Epic, Care Everywhere and outside locations to gather required information before submitting for authorization.
  • Determines necessity for pre-authorization for each CPT code via phone call or portal review.
  • Initiates prior authorization via portal, fax form or via telephone call; uploading or faxing clinicals per insurance requirements for ancillary tests (CT, MRI, EEG, EMG, Sleep studies, etc), treatment and/or procedure(s) conducted in the Neuroscience Group office and/or outside locations.
  • Regularly follows up on pending authorization requests so they are addressed in a timely manner via portal or phone call.
  • Notifies patients and practitioners of any services requested and/or referred that are not authorized by insurance.
  • Reviews denied cases for additional information required/reason for denial; communicates reason for denial to practitioner for guidance on next steps. Ie. Peer to Peer or Appeal
  • Schedules Peer to Peer based off of criteria, reason for denial and provider schedule.
  • Collaborates with provider on completion of appeal letter for submission to insurance.
  • Maintains good communication with the patient, physician, clinical services team, reimbursement services team, and outlying facility staff.
  • Daily use of Faxfinder cloud faxing system for managing incoming and outgoing faxes.
  • Maintains timely, complete documentation and recordkeeping to ensure accurate continuity of patient care.
  • Regularly attends all team and staff meetings
  • All other temporary and/or permanent duties as assigned by the Team Leader of Prior Authorization Specialist


Requirements:
  • Previous experience in medical preauthorization/precertification
  • Knowledge of health care insurance and third-party payers. (VA, Work Comp)
  • Previous experience with CPT and ICD-10 coding
  • Prior EPIC experience
  • Team Player who can also work independently

KNOWLEDGE/SKILLS REQUIRED TO BE SUCCESSFUL IN THIS POSITION:

  • Proficient computer knowledge and keyboarding skills (Microsoft Office programs)
  • Medical terminology
  • Excellent verbal and written communication skills
  • Customer service experience
  • Strong organizational skills
  • Detail-oriented
  • Ability to multi-task and remain focused while managing a high-volume, time-sensitive workload
  • Critical thinking skills and decisive judgment

TYPICAL PHYSICAL DEMANDS AND WORKING CONDITIONS:

  • Primarily seated work but will require some position change including bending, stooping, and stretching.
  • May involve lifting supplies up to 20 to 30 pounds.
  • May occasionally need to assist with wheelchair transfers.
  • Requires hand-eye coordination and manual dexterity sufficient to operate standard office equipment.
  • Requires normal range of hearing and eyesight in order to communicate and function within this setting.

BENEFITS:

At Neuroscience Group we offer a very competitive salary. In addition to great pay we also offer the following benefits:

  • No nights, no weekends, and no holidays
  • Health Insurance
  • Health Savings Accounts with a generous employer contribution
  • Dental Insurance
  • Vision Insurance
  • Company paid Long Term Disability and Life Insurance
  • Voluntary Life and Short Term Disability Insurance
  • Voluntary Accident and Critical Illness Insurance
  • Generous PTO and Sick Banks
  • 401(k) with guaranteed employer contribution, Profit Sharing, and a Cash Balance Pension Plan
  • Employee Assistance Program
  • Timber Rattler tickets
  • Holiday party, summer picnic, and annual recognition for years of service
  • Annual Employee Appreciation Day


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