Job Description

POSITION/JOB SUMMARY:

• The Prior Authorization Specialist is responsible for the end-to-end management of insurance authorizations for Johnson Memorial Health Services’ patients. Acts as a central resource for providers and nursing staff to obtain necessary approval for patient services. This role will require daily interaction and communication with JMHS providers, nurses and revenue cycle staff to manage authorizations. 

The Prior Authorization Specialist works day shifts Monday - Friday.

ESSENTIAL FUNCTIONS

• Manage insurance authorization process for all JMHS departments
• Review patient records and/or talk with nursing staff or provider to determine CPT codes and diagnoses codes needed for authorization
• Check to see if authorization is needed for scheduled and same day services
  1. Check various payer websites, portals, and/or call
• Pull all medical records necessary to submit with authorizations
• Submit authorizations when required – authorizations may need to be completed electronically, faxed or called in based on payer.
• Follow up on submitted authorizations to ensure approval before services are provided
• Record prior authorization details including approval dates, billing units, procedure codes, and authorization numbers.
• Track and renew expiring authorizations.
• Secure patient demographics and medical information in compliance with HIPAA regulations.
• Assist business office staff with appeals for claims denied for no prior authorization
• Stays informed of insurance requirement changes by reviewing bulletins related to prior authorization requirements
• Attend various meetings to stay informed and communicate changes related to services requiring authorization
• Complete required annual Health Care Academy lessons
• Follow the Standards of Behavior at all times
• Gather necessary information that may be requested by the manager
• Continuous quality improvement
• Help others succeed.
• Other duties as assigned.

STANDARD REQUIREMENTS

• Supports the Mission, Vision and Values at Johnson Memorial Health Services.
• Is knowledgeable of patient and resident rights and ensures an atmosphere which allows for the privacy, dignity, and well-being of all patients and residents in a safe, secure environment.
• Supports, cooperates with, and implements specific procedures and programs for:
  • Safety, including universal precautions and safe work practices, established fire/safety/disaster plans, risk management, and security, report and/or correct unsafe working conditions, equipment repair and maintenance needs.
  • Confidentiality of all data, including patient, resident, employee, and operations data.
  • Quality assurance and compliance with all regulatory requirements.
  • Compliance with current law and policy to provide a work environment free from any sort of harassment and all illegal and discriminatory behavior.
• Supports and participates in common teamwork:
  • Cooperates and works together with all co-workers; plan and complete job duties with minimal supervisory direction including appropriate judgment.
  • Uses tactful, appropriate communication in sensitive and emotional situations.
  • Follow up as appropriate with supervisor, co-workers, patients, or residents regarding reported complaints, problems, and/or concerns.
  • Promotes positive public relations with patients, residents, family members and guests.
  • Completes requirements for in-service and annual training, acceptable attendance, uniform dress codes including personal hygiene, and other work duties as assigned.

QUALIFICATIONS

• Candidates should have prior authorization experience or an intermediate understanding of medical terminology. CMA or LPN credentials are preferred.
• High School Diploma or GED required
• Clinical healthcare knowledge and experience preferred
• Ability to communicate effectively with the public, patients, and co-workers
• Able to build relationships and work closely with numerous departments
• Knowledge in Word and Excel
• Ability to understand various insurance payers and plans
• Epic system experience preferred
• Ability to navigate websites and portals
• Ability to deal with ambiguity
• Ability to multi-task and deal with shifting priorities in a fast-paced work environment

MINIMUM PHYSICAL REQUIREMENTS  

• Tools/Equipment Used:  Standard office equipment including computer and peripherals.
• Posture:  Prolonged sitting; occasional bending/stooping, pushing/pulling, and twisting.
• Motion:  Repetitive hand motions, frequent keyboarding, and use of mouse; occasional reaching.
• Lifting:  Occasional light lifting and carrying (less than 35 pounds).

Benefits Offered for 48+ hours (.6 FTE)

• Medical Insurance
• Dental Insurance
• Vision Insurance
• Life Insurance
• Flexible Spending (FSA)
• Health Savings (HSA)
• Supplemental Insurances
• Retirement (401a/457 Plan) 
• Paid Time Off 
• Employee Sick & Safety Leave
• Extended Illness Bank

We're an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.

JHMS is committed to the full inclusion of all qualified individuals. As part of this commitment. JHMS will ensure that persons   with disabilities are provided reasonable accommodations. If reasonable accommodation is needed, please contact the Human Resources Department.

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