Prior Authorization Specialist

The position of Prior Authorization Specialist is responsible for processing prior authorization requests for imaging, procedures, and prescriptions. Serves as a backup when other prior authorization specialists are out to ensure seamless flow of department. 

ESSENTIAL FUNCTIONS

(1) Processes prior authorization requests for imaging, prescriptions, and procedures. This may include receiving requests via EMR messages from provider teams, faxes or telephone calls from pharmacies, or working the schedule to review where authorizations are needed. Requests authorizations by speaking directly with insurance company representative by phone or via internet portals. Expedites urgent requests.

(2) Ensures that accurate and required clinical documentation is in patient charts to send with prior authorization request. 

(3) Uses Clinic Forms and Patient Notes to document prior authorization process and status. 

(4) Remains current on insurance regulations and policies pertaining to pain management procedures and prescriptions. Research individual insurance policies to determine coverage. 

(5) If authorization for imaging is received, the position uploads the authorization to the patient’s chart, contacts the patient and the imaging center to schedule an appointment, and enters the appointment time and date in the chart notes.

(6) If authorization for procedure is received, auth is uploaded into the chart and the provider team is notified. If procedure is denied, provider team is notified, and patient is contacted to cancel procedure if needed. 

(7) Sends appeals in for denied prior authorizations or contacts the provider teams to obtain additional clinical information to overturn denial. 

(8) Monitors imaging appointments and checks the patient’s chart within 48 hours after the appointment to determine if an imaging report has been received and added to the chart, and messages provider team to notify. If the imaging report has not been received, the position contacts Medical Records to request the imaging report from the imaging center.

(9) Follows up with patients who request an update on a prior authorization request or have other questions in a timely and courteous manner.

(10) Performs other related duties as required. 

CORE COMPETENCIES

· Excellent oral and written communication skills

· Strong telephone communication skills

· Knowledge of current medical terminology to communicate with physician, staff, and patients

· High level of attention to detail

· Strong organization, filing, and time management skills

· Basic computer literacy and typing

· Patient focused

REQUIRED  REQUIRED EDUCATION, EXPERIENCE, AND/OR CERTIFICATIONS

The position requires a high school diploma or educational equivalent and one (1) year of experience in healthcare insurance verification or medical authorization or the equivalent.