Pre-Authorization Coordinator assumes responsibility for providing accurate and complete data input and follow up for precertification requests while offering excellent customer service.
JOB RELATIONSHIPS:
1. Responsible to the Director of Operations.
2. Other relationships: Works closely with Providers,3rd Party Payers, Manager Care Organizations and their contracted benefits companies, Nurses, Medical Assistants, Medical Records, and the Referral Coordinator.
RESPONSIBILITIES AND AUTHORITIES:
1. Works as an integral member of the health care team.
2. Communicates with provider practices, hospitals, patients, families, insurance companies and others using exemplary customer service skills.
3. Works with patient's insurance companies to pre-certify/authorize procedures/testing as ordered by referring physician.
4. Accurately enter required information into applicable structured fields via electronic or paper format depending on payer's process for approval.
5. Provide necessary information for review and consideration of pre-authorization request
6. Contact applicable providers/practices with precertification numbers as needed. Forward completed requests to Medical Record department for scanning
7. Refers patients to their insurance coverage benefit departments of correct claims administrator when requesting benefit information.
8. Reviews documentation from referring provider to meet the needs of the payee. Contracts physician/provider offices to obtain missing documentation to complete orders.
9. Communicates with patients/parents to request additional documentation
10. Once order is complete, will contact patient to confirm receipt of order and inform patient he/she will be contacted to inform of outcome of the pre-authorization request
11. Communicates with practice care teams to keep them updated.
12. Assists with any denied requests to resolve any issues.
13. Keeps abreast of industry trends and regulatory changes and incorporate job duties.
14. Other duties as assigned by supervisor.
KNOWLEDGE/SKILLS/ABILITIES:
In addition, individual must possess the knowledge and these skills and abilities or be able to explain and demonstrate that the individual can perform the primary functions of the job with or without reasonable accommodation using some other combination of skills and abilities and to posses the necessary physical requirements with or without the aid of mechanical devices to safely perform the primary functions of the job.
1. Physical requirements include the ability to extend hand(s) and arm(s) in any direction; pick, pinch, type or otherwise work primarily with fingers; stand for sustained periods of time and move about on foot to accomplish tasks, raise objects from a lower to a higher position or move objects horizontally from position to position; apply pressure to an object with fingertips; sustain substantial movement of wrists, hands and/or fingertips.
2. Ability to express or exchange ideas by means of the spoken word.
3. Ability to receive detailed information through oral communication and make fine discrimination in sound.
4. Ability to interact effectively with people of varied educational, socioeconomic and ethnic backgrounds, skill levels and value systems; to work with frequent interruptions and to respond appropriately to unexpected situations. Excellent listening skills.
5. Ability to exert up to twenty (20) pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, punch, pull, or otherwise move objects. Primary functions involve sitting, as well as stooping, kneeling, crouching, and reaching; walking, particularly for long distances, and standing for sustained periods of time.
6. Visual acuity sufficient for work which deals largely with visual inspection involving small anatomical or physiological details as well as the whole patient, preparing and analyzing data and figures, accounting, computer terminal operation, extensive reading, and visual inspection involving small parts/defects.
7. Excellent written, verbal communication and social skills.
8. Ability to endure periods of heavy workload or excessive stress.
9. Ability to wear equipment such as safety glasses, gowns, etc.
10. Knowledge of database and spreadsheet software systems. Computer skills preferred and basic financial skills, as well as analytical skills for trend and situational analysis desired.
11. Ability to transport self to meetings, event and affiliated vendors.
12. Not substantially exposed to adverse environmental conditions.
13. Based on the mental requirements of the position, please check below the ADA statement that best fits the position. Choose ONLY ONE from below:
? Requires the ability to understand and follow simple instructions and to use simple equipment involving few decisions.
? Requires the ability to perform repetitive or routine duties working from detailed instructions and understand procedures. Requires the making of minor decisions.
? Requires the ability to plan and perform diversified duties requiring an extensive knowledge of a particular field and the use of a wide range of procedures. Involves the exercise of judgment in the analysis of facts and conditions regarding individual problems or transactions to determine what actions should be taken within the limits of standard practice.
? Requires the ability to plan and perform a wide variety of duties requiring general knowledge of policies and procedures. Requires considerable judgment to work independently toward general results, devising methods, modifying or adapting standard procedures to meet different conditions, making decisions based on precedent and policy.
? Requires the ability to plan and perform difficult work where only general methods are available. Involves highly technical or involved projects, presenting new or constantly changing problems. Requires outstanding judgment and initiative in dealing with complex factors not easily evaluated, also making decisions for which there is little precedent.
? Requires the ability to plan and perform complex work that involves new or constantly changing problems where there is little accepted method or procedure. Involves participation in the formulation and carrying out of policies, objectives and programs for major divisions or functions. Considerable ingenuity and exceptional judgment required to deal with factors not easily evaluated, interpret results and make decisions carrying a great deal of responsibility. Direct and coordinate the work of subordinate supervision in order to attain objectives.
REVIEWED AND REVISED: 10/02
QUALIFICATIONS:
Education: . High School education; Medical Assistant training graduate preferred
Experience: Two years of experience in Health Care field.