Medical Authorization Specialist

J  o  b    D  e  s  c  r  i  p  t  i  o  n

          Joy                         Care                      Competence                    Respect

Position Summary

The Medical Authorization Specialist obtains prior authorizations and reviews medical necessity requirements for upcoming services.  This role collaborates with other departments and providers while maintaining professional communication and interpersonal skills.

High School Diploma or equivalent is required.

Associates degree in Business or a related field is preferred.

Completion of a medical terminology course is preferred.

2 years of experience in healthcare or clerical administration or formal education in a related field is required.

Experience working with various payors including Medicare, Medicaid and Private Payer, as it relates to medical procedures, service, and devices is preferred.

Epic experience is preferred.

Prior experience navigating software platforms is preferred.

N/A

Demonstrates the ability to multitask and maintain a strong attention to detail, with good analytical and problem-solving skills.

Proficient in computer navigation skills. 

Ability to work independently and proficiency.

Strong verbal communication and listening skills.

Demonstrates excellent judgement and decision making skills.

Demonstrates the ability to maintain confidential information.

Demonstrates a friendly and service-oriented client experience.

Provides timely follow up on pending or denied cases.

Documents each result of the authorization request in the referral or authorization/certification throughout the resulting process.

Initiates and serves as a gatekeeper over requests for prior authorization electronically, by phone or paper.

Communicates with the prescribing office or clinic staff about a request.

Uploads appropriate medical documents from ROI or Media into insurance portals or by fax.

Reviews medical necessity policies to ensure the procedure and diagnosis meet the requirements.

Follows our escalation process to providers, other revenue cycle colleagues and leadership when required.

Confirms a patient's insurance covers a procedure or service.

Contacts insurance companies, providers, or responsible parties to verify orders/case request and coverages when appropriate.

Possess the information, skill, and understanding of the work to be performed.  Actively participates in continuing education opportunities and maintains certifications, licensure as appropriate.

Abides by all safety requirements including demonstrating proper hand hygiene and wearing of Personal Protective Equipment (PPE), if applicable. 

Complies with all standards, policies and procedures including dress code, attendance and punctuality.  Attends required in-services and meetings and completes all mandatory competencies by deadline. Commits to keeping all patient, student or colleague information confidential and maintains ongoing communication and collaboration with team members. 

The purpose of this job description is to provide a summary of the major responsibilities performed by colleagues in this position. Colleagues may be requested to perform tasks other than those specifically presented in this job description.  Variances in job duties performed may exist between facilities, and colleagues may perform other related duties as assigned to meet the needs of the organization.

PHYSICAL, MENTAL AND ENVIRONMENTAL REQUIREMENTS

Physical, Mental and Environmental Requirements Category:

Administrative

Standing

X

Walking

X

Sitting

X

Lifting

X

20 lbs.

Carrying

X

20 lbs.

Pushing

X

20 lbs.

Pulling

X

20 lbs.

Climbing

X

Balancing

X

Stooping

X

Kneeling

X

Crouching

X

Crawling

X

Reaching

X

Use of Hands/Dexterity

X

Talking

X

Hearing

X

Eye/Hand/Foot Coordination

X

Extreme Cold

X

Extreme Heat

X

Humid

X

Wet

X

Noise

X

Hazards

X

Temperature Change

X

Atmospheric Conditions

X

Vibration

X

Other