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Prior Authorization Specialist

2 months ago

Scottsdale, Arizona, United States HonorHealth Full time
Job Summary

The Prior Authorization Specialist is a key member of the Utilization Management Department, responsible for reviewing requests for authorization of services and coordinating the timely completion of the authorization process. This role requires strong clinical knowledge and analytical skills to ensure that patient care is delivered in a timely and efficient manner.

Responsibilities
  • Receive and review referral and admission requests from practices and acute/post-acute facilities, verifying patient demographic and insurance information within the billing system.
  • Coordinate the PA process in MCG software, ensuring appropriate documentation for criteria is met, and approve requests or send them for Medical Director/designee review if criteria and guidelines are not met.
  • Mentor new PA staff in areas such as role and quality/regulatory alignment, maintaining a productivity PA case load of an average of 10 prior auth processing per day.
  • Assist in tracking quality metrics and maintaining departmental regulatory compliance, and take on a lead role on the team under the direction of the manager in their absence.
  • Request additional information from medical office staff members and referring physicians as necessary, and identify potential risk/quality management cases using established criteria and refer to Director.
  • Maintain accurate logs of PA authorizations within software, date stamp all received documents sent to organization for processing, and obtain prior authorizations and referrals from practices in accordance with organization's requirements using website and fax systems.
Qualifications

An Associate's Degree or 2 years' work-related experience in Business, Health Administration, or a related field is required. Additionally, 3 years of prior authorization experience and 3 years as a PA specialist are required.