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Authorization Review Specialist

2 months ago

Scottsdale, Arizona, United States HonorHealth Full time

Overview:
Are you looking to contribute to a significant cause? At HonorHealth, you will join a dedicated team focused on delivering a comprehensive care experience for our patients. You will have the chance to make a real impact through various initiatives and extensive training programs tailored to your professional growth.

HonorHealth provides a wide-ranging benefits package for both full-time and part-time employees, designed to support you and your family in leading fulfilling lives. Discover more about our offerings.

Join us in our mission to exceed expectations and innovate healthcare together.

HonorHealth stands as one of Arizona's largest nonprofit healthcare organizations, catering to a population of five million in the greater Phoenix area. Our extensive network includes six acute-care hospitals, a vast medical group offering primary, specialty, and urgent care services, a cancer care network, outpatient surgery centers, clinical research, medical education, a foundation, an accountable care organization, community services, and more. With nearly 14,000 team members, 3,700 affiliated providers, and numerous volunteers committed to delivering high-quality care, HonorHealth aims to surpass the traditional healthcare model to enhance the health and well-being of communities throughout Arizona. Learn more about our organization.

Qualifications:
Education:
High School Diploma or GED is required.

Experience:
Minimum of 1 year of experience in health plan-based prior authorization is required.

Responsibilities:
Job Summary:
The Prior Authorization (PA) Specialist plays a crucial role in reviewing requests for service authorizations and ensuring the timely completion of the authorization process within the Utilization Management Department. The PA Specialist will evaluate referral and admission requests, confirm eligibility and benefit details, and assess whether adequate clinical information has been provided for review according to health plan, CMS, MCG, or other nationally recognized criteria/guidelines. Approvals for referrals and admissions will be granted if the established criteria and guidelines are satisfied.

  • Processes referral and admission requests from healthcare practices and acute/post-acute facilities. Verifies patient demographic and insurance details within the billing system. Manages the PA process using MCG software and ensures that appropriate documentation meets the criteria. Approves requests or escalates them for review by the Medical Director/designee if the criteria are not met. Maintains a productive PA caseload averaging 10-15 prior authorization processes daily.
  • Requests additional information from medical office staff and referring physicians as needed.
  • Identifies potential risk and quality management cases using established criteria and refers them to the Director. Coordinates PA-related issues with the organization's Medical Director/Designee. Adheres to the organization's PA policies and procedures while maintaining professional conduct and fostering positive relationships with colleagues, supervisors, and other provider practices.
  • Keeps accurate logs of PA authorizations within the software, date-stamping all received documents sent for processing. Obtains prior authorizations and referrals from practices in accordance with the organization's requirements using online platforms and fax systems. Reviews medical records within IE and/or EPIC to ensure appropriate submissions for authorization requests.