Prior Authorization Coordinator

Description

Hours and Days:

Monday - Friday; 8:00 AM - 5:00 PM | No Weekends | No Holidays

Job Title: Prior Authorization Coordinator

Department: Business Office

Reports To: Chief Financial Officer

Position Summary: Ensure patients receive appropriate care while bridging the gap between clinical and financial operations. Work in collaboration with medical staff, nursing staff, and ancillary services to ensure that prior authorization requests are completed in a timely fashion. This includes appeals, peer to peers, and/or reviews conducted using evidence based standards. May be in direct collaboration with providers or facilities outside of KCHS.

Essential Job Functions Duties and Responsibilities

Data Collection

• Must be able to abstract and compile data from patient’s clinical chart. This includes the KCHS EMR as well as supporting data from other hospitals, clinics, or imaging centers.
• Document all activity within the EMR system for future reference.

Website navigation

• Must be able to input qualifying clinical data into multiple insurance data banks and websites, as well as navigate the sites to ensure coverage for patients at KCHS. Such sites

Communication

• Communicates with physicians, ancillary providers, nursing staff, and other hospital departments to coordinate care.
• Updates providers, nursing staff, and patients regarding the status of the prior authorization with insurance.
• Assists patients with insurance questions relating to prior authorizations.
• Works with RHC staff to do prior authorization for prescriptions medications for clinic patients.

Prospective, Concurrent and Retrospective Reviews

• Analyze patient cases before prior authorization or patient estimates to ensure medical necessity and appropriateness.
• Evaluate ongoing medical necessity during extended inpatient and skilled nursing episodes, if the payer is commercial.
• Review clinical and billing data after care has been performed, to identify opportunities for improvement.

General Requirements:

Personal Responsibilities

• Works in harmony with assigned co-workers and other department staff.
• Is punctual in attendance. Adjusts personal schedule to work as scheduled. Provides proper notification for absence as per hospital policy.
• Accepts and responds to constructive criticism, assigned duties and suggestions in a cooperative manner.
• Demonstrates the ability to accept and implement change
• Completes assignments accurately and on time.
• Participates in continuing education programs and staff meetings as evidenced by attendance records.
• Where applicable, floats to other areas as assigned; responds to floating requested with a positive attitude.
• Willingly accepts assignments to special projects.
• Attentive to detail, record-keeping and required paperwork inherent to the position.
• Demonstrates kindness, courteousness, and sensitivity to patients, families, physicians, co-workers and visitors at all times.
• Appears well groomed and observes established dress guidelines, visibly wearing the name identification badge.
• Displays self-respect and pride in KCHS.

Customer Service

• Assists all patients, family members/significant others, physicians, visitors and employees in a friendly manner.
• Introduces self and uses caring, thoughtful words either in person or on the telephone.
• Demonstrates ethical and appropriate behavior for a healthcare environment to include, but not limited to, dignity, patient’s rights and privacy, and the maintenance of confidentiality of patient information.
• Demonstrates caring. If unable to assist an individual in needs, offers to find someone who can.
• Demonstrate proper telephone etiquette. If transferring a telephone call, announces the caller and briefly explains the situation before ending the transfer.
• Makes eye contact when speaking with patients, family members/significant others, visitors, employees, etc. Knocks before entering a room or office. Addresses all individuals courteously.
• Keeps voice down, does not shout or use improper language. Responds to all inquiries promptly and courteously.
• Shares information so that the people who need to be aware of the facts are informed.

Risk Management & Safety Program

• Demonstrates adherence to risk management and safety policies and codes as evidenced by in-service attendance records and employee practices.
• Maintains a clean and safe environment for patient and co-workers.
• Follows all general safety rules.
• Notifies the Safety Director and/or Risk Manager of incidents involving injury or having the potential for injury. Submits incident reports according to hospital policy.

Patient Interaction

• Provides estimates of financial liability to patients based on services to be received and existing coverage.

Requirements

Educational Responsibilities

• Completes required careLearning modules
• Completes other required certifications or classes as necessary to perform the essential functions of the job.

Qualifications:

Education and/or Experience:

• High School Diploma or equivalent
• Associate’s Degree or greater in finance, business, health information management, or other relevant field preferred
• Prior relevant experience (such as health information management, coding, nursing, insurance, financial position, etc.) preferred

Knowledge, Skills and Abilities:

• Ability to work cooperatively and communicate effectively to maintain good working relationships with staff, healthcare providers, patients, and insurance companies
• Must be capable of communicating clearly (reading, writing and speaking) in the English Language.
• Must be proficient in the operation of a personal computer with Microsoft Office and the Internet
• Must be capable of reading and comprehending complex healthcare laws and regulations