Prior Authorization Specialist I

Description

CORE VALUES 

The core values of Community Health Center of Southeast Kansas, Inc. (CHC/SEK) are dignity and stewardship. Each staff member is expected to perform their job duties in a way that preserves dignity for our patients and maintains good stewardship of CHC/SEK’s resources. 

GENERAL DESCRIPTION

The Prior Authorization Specialist I is responsible for diagnostic and procedure orders management, including completing prior authorizations, scheduling appointments, obtaining order results, and submitting results to the ordering provider. The Prior Authorization Specialists I assists patients with applications for programs to support the financial obligations needed to complete screening exams, and scheduling in-house diagnostic exams. 

Requirements

ESSENTIAL DUTIES

1. Reviews order within the Electronic Health Record System with insurance companies to determine need for prior authorization. 
2. Processes prior authorizations and sends any supporting documentation to insurance companies to expedite the prior authorization process. 
3. Schedules diagnostic imaging and procedure appointments appropriate for the patient’s needs, internally or externally. 
4. Manage correspondence with insurance companies, physicians, specialist and patients, as needed, including documenting in the EHR as appropriate.
5. Reviews denials and follows up with the provider to obtain medically necessary information to submit an appeal of the denial.
6. Prioritizes orders by level of urgency. 
7. Requests order results from external facilities and submits the results to the order provider to support continuation of care. 
8. Assists patients with program applications to finance screening diagnostic imaging exams. 

QUALIFICATIONS AND SKILLS

1. High school diploma or equivalent.
2. At least 1 year of experience in a healthcare setting preferred.
3. Knowledge of insurance processes and medical terminology preferred.

KNOWLEDGE, SKILLS AND ABILITIES

1. Social and cultural sensitivity appropriate to ethnically and economically diverse patient-and employee-base.
2. Communicates through appropriate channels. Use proper chain of command for patient complaints.
3. Ability to handle emergency situations calmly and effectively.
4. Must be computer literate and able to navigate through the Electronic Health Record.
5. Must be able to maintain good inter-personal relationship with co-workers and other members of the health care team and the organization.
6. Provide customer service in accordance to the organization’s mission.
7. Be courteous and respectful when interacting with patients and family members.
8. Maintain patient confidentiality in accordance to organization’s policy and procedure and HIPAA requirements.

WORKING CONDITIONS

While performing the duties of this Job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms and talk or hear. The employee is occasionally required to stand. The employee is occasionally required to walk. The employee must occasionally lift and /or move up to 10 pounds. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception and ability to adjust focus. Computer work is frequent. Good lighting and comfortable temperature of ventilation at all times.