Specialist, Prior Authorization & Forms

JOB SUMMARY

The prior authorization & forms specialist handles pre-certification, authorizations and coordination among patients, third party payers and practice, including routine and medical office visits, lab work, diagnostic testing, procedures and surgeries. This position will be responsible for monthly invoicing reconciliation with Billing and Finance. This position will work with all the Medical departments. This position may be remote. 

REPORTING RELATIONSHIPS

The position reports to the Practice Manager. No positions report to this role.

ESSENTIAL JOB DUTIES and FUNCTIONS

This position will perform the following duties while living and demonstrating the Core Values:

• Receive prior auth request from physician or pharmacy
• Submit all info via Navinet insurance website
• Verify diagnosis code via medication screen or chart notes
• Research alternatives that patient has tried and list them on prior auth
• Use chart notes to answer questions that are prompted via the insurance company
• Verify that all information is accurate
• Submit prior auth request
• Input info into Medication Prior Auth Flowsheet in medent and add to to-do to keep track of auth
• If prior auth is approved notify provider and send approval notice to pharmacy
• If medication is for prolia, add to-do for six months from approval date to submit new prior auth
• If prior auth is denied reach out to Dr. to see if they want to switch medication, or if they want to appeal denial.
• If Dr. wants to appeal, research what info the insurance is requesting and send prior auth form and any necessary documents to insurance for appeal
• Update insurance companies as necessary
• Receive referral in referral box or via triage
• Call patient to set up appointment
• If patient answers, go into Rheumatology provider’s schedule to find best time to schedule apt
• Fill out referral date and time for appointment
• Proceed to schedule appointment
• Process unable to contact letters as needed
• Ensure all home health forms are signed by Physician and sent back to appropriate area
• FMLA forms processing
• Follow all rules of forms policy
• Process school, college & medical forms that are non nurse required
• Parking placards
• Ensure all forms meet The Wright Center policy requirements

Qualifications:

• High school diploma or equivalent
• Previous front-office experience (2-4 years) in a high volume medical practice desirable
• Previous experience with insurance preferred
• Experience with MEDENT or other EMR software a plus
• Knowledge of medical terminology and insurances
• Proficiency in Word, Excel, PowerPoint and E-mail
• Must be reliable and punctual
• Must have attention to detail
• Must be able to perform effectively in a fast paced environment with many changing priorities
• Must be professional and customer service oriented to deliver quality excellent care
• Ability to work independently and with a team
• Professional written and verbal communication and interpersonal skills
• Willingness to work a flexible schedule