Job Title: Prior Authorization Specialist

Department: Business Office

Immediate Supervisor: Director of Administrative Services

Job Responsibilities: Responsible for all aspects of the prior authorization process. Responsibilities include collecting all the necessary documentation, contacting the patient as needed for additional information and completion of the required prior authorization for procedures and tests ordered by the provider.

Examples of Duties: (This list may not include all of the duties assigned.)

1) Call insurance carriers for prior authorization or permission to obtain precertification if insurance requires.

2) Obtain precertification or prior authorizations for procedures and/or other tests ordered by Kansas Gastroenterology, LLC providers.

3) Submit clinical information to insurance for prior authorizations, pre-certs and pre-determinations when requested by insurance. i.e., Capsules, imaging, ultrasounds etc.

4) Enters referrals/authorizations to patient registration on EMR.

5) Enters notes to accounts regarding benefit details and policy information.

6) Effectively communicate with staff in regards to a status of a prior authorization as needed.

7) Maintain the collection log for procedures in our ASC. Verify benefits on patients and call to obtain pre-payments if needed prior to scheduled procedure (s).

PERFORMANCE REQUIREMENTS

Knowledge, Skills and Abilities:

1. Knowledge of billing and EMR systems.

2. Knowledge of organizational policies, regulations and procedures.

3. Understand insurance policies in regard to benefits, pre-certifications, prior authorizations, etc.

4. Skill in establishing and maintaining effective working relationships with insurance carriers, PCP offices and internal staff.

5. Ability to react calmly and effectively in stressful situations.

6. Ability to interpret, adapt and apply guidelines and procedures.

7. Ability to communicate clearly verbally and in writing.

Education: High School Graduate

Experience: Clinical knowledge and terminology along with a strong insurance background.

Equipment Operated: Requires use of computer, fax, scan, etc.

Work Environment: Individual cubicle. Controlled lighting, acoustics, air quality and temperature settings. Environmental hazards may be unpredictable including exposure to communicable diseases.

Mental/Physical Requirements: Involves standing, walking, bending, grasping, manipulating, long periods of computer work and consistent phone calls. Occasional need to lift supplies, equipment, etc. with or without assistance. Stress can be triggered by workload and complex cases.

Pay is commensurate with experience.