Medical Authorization Specialist

3 weeks ago

Houston, Texas, United States Premier Medical Resources Full time
Prior Authorization Specialist Job Description

Premier Medical Resources is a healthcare management company that aims to leverage the expertise of its employees to drive quality in all aspects of its operations. We strive to create career pathways for our employees, from those just starting their professional journey to those seeking to bring their expertise and leadership to the table.

The Prior Authorization Specialist will play a crucial role in ensuring that the required pre-certifications, pre-authorizations, and referrals for all services are obtained accurately and timely. Under the direction of the Revenue Cycle Manager, the employee will be responsible for overseeing the processes within the department to ensure they are functioning appropriately.

Key Responsibilities:

  • Prioritize incoming authorization requests according to urgency.
  • Generate, verify, and oversee the complete procedure authorization/referral process.
  • Manage and resolve day-to-day issues pertaining to pre-authorization, as needed.
  • Monitor provider network status and notify appropriate individuals of non-network status providers.
  • Obtain authorization by fax, payer website, or by phone and follow up regularly on pending cases.
  • Notify appropriate departments for approvals and denials.
  • Initiate and assist with appeals for denied authorizations.
  • Notify and coordinate P2P (Peer to Peer) requests with the appropriate department.
  • Confirm accuracy of CPT and ICD-10 diagnoses in the procedure order.
  • Contact patients as needed to discuss authorization status.
  • Effectively maintain, monitor, and update payer medical policy guidelines to manage authorization requirements.
  • Request, review, and submit necessary patient documentation as needed.
  • Assist with patient scheduling and inquiries, as necessary.
  • Effectively utilize ICD 10, CPT, modifiers, and/or other codes according to coding guidelines.
  • Communicate effectively with providers and/or all appropriate parties regarding missing information such as CPT, diagnoses codes, documents, clinical reports, etc. to ensure proper authorization processing.
  • Communicate effectively with other departments regarding changes and/or updates with patient accounts and status.
  • Manage the status of accounts and identify inconsistencies.
  • Respond to billing inquiries.
  • Use downtime efficiently; be aware of team members' workload.
  • Communicate company goals, expectations, updates, and/or deadlines timely.
  • Make recommendations on workflow improvement as needed.
  • Report statistics as required.

Requirements:

  • Knowledge with in and out of network insurances, insurance verification, patient responsibility, and process for prior authorization.
  • Familiarity with ICD-10 and CPT codes and procedures.
  • Ability to review and understand patient medical documentation.
  • Ability to independently identify and understand medical necessity requirements.
  • Task-oriented and organizational skills; ability to complete tasks timely.
  • Detail-oriented focus; being careful about detail and thorough in completing work tasks.
  • Ability to work independently and as a team.
  • Ability to adapt with flexibility.
  • Effective communication skills (written/verbal).

Education and Experience:

  • High school diploma or GED.
  • Two (2) years of medical office or facility setting experience.

Benefits:

  • 3 Medical Plans.
  • 2 Dental Plans.
  • 2 Vision Plans.
  • Employee Assistant Program.
  • Short- and Long-Term Disability Insurance.
  • Accidental Death & Dismemberment Plan.
  • 401(k) with a 2-year vesting.
  • PTO + Holidays.

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