Authorization Specialist- HVI, Children's Hospital

Life in Pittsburgh; Pittsburgh (Allegheny County); On-site; USD 52,000 - 64,000; Full time

Job summary

UPMC is seeking an Authorization Specialist for the Heart and Vascular Institute at Children’s Hospital of Pittsburgh. The role is full-time, on-site, Monday–Friday 8:00am–4:30pm, with prior authorization and scheduling experience required.

Responsibilities include pre-authorizations, denial management, and revenue functions, using ICD-9-CM, CPT, and HCPCS. Strong communication skills and proficiency in Microsoft Office are essential to ensure timely, accurate authorizations.

Qualifications

• High School diploma or equivalent with 2 years in medical environment or Associate's degree with 1 year experience; Bachelor's preferred.
• Must understand medical terminology, ICD-9, CPT Codes.
• Proficient in Microsoft Office.
• Excellent communication and interpersonal skills.
• Ability to analyze data and exercise independent judgment.
• Experience with web-based computerized systems.
• Knowledge of authorization processes and payer guidelines.

Responsibilities

• Perform pre-authorizations and denials management for inpatients, outpatients, and ED.
• Review medical records to determine medical necessity and pre-authorize procedures.
• Submit demographic and clinical data to payors for approvals.
• Ensure compliance with quality standards and coordinate with Physician Services and Hospital Division.
• Utilize UPMC systems and payor websites to process authorizations, edits, and denials.
• Resolve basic authorization edits to minimize claim delays.

Skills

Medical terminology

ICD-9-CM codes

CPT codes

Microsoft Office

Communication skills

Data analysis

Independent judgment

Web-based system usage

Education

High School diploma or equivalent

Associate's degree in medical environment

Bachelor's degree (preferred)

Job description

University of Pittsburgh Physicians is hiring a full-time Authorization Specialist for the Heart and Vascular Institute at Children's Hospital of Pittsburgh. This position will work on-site Monday-Friday 8:00am-4:30pm. Previous experience in Authorization and Scheduling is required.

Purpose:

To perform authorization activities of inpatient, outpatient and emergency department patients, denial management and all revenue functions. Need to demonstrate, through actions, a consistent performance standard of excellence to which all work is to conform. The expertise of the Authorization Specialist shall include working knowledge in the area of authorization related activities including pre-authorizations, notifications, edits, denials, etc. The Authorization Specialist shall demonstrate the philosophy and core values of UPMC in the performance of duties.

Responsibilities:

• Prior authorization responsibilities1. Reviews and interprets medical record documentation for patient history, diagnosis, and previous treatment plans to pre-authorize insurance plan determined procedures to avoid financial penalties to patient, provider and facility. 2. Utilizes payor-specific approved criteria or state laws and regulations to determine medical necessity or the clinical appropriateness for inpatient admissions, outpatient facility, office services, durable medical equipment, and drugs in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury, or disease. 3. Ensures accurate coding of the diagnosis, procedure, and services being rendered using ICD-9-CM, CPT, and HCPCS Level II. 4. Provides referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive nonclinical administrative time required of providers. 5. Submits pertinent demographic and supporting clinical data to payor to request approval for services being rendered.
• General responsibilities:1. Maintains compliance with departmental quality standards and productivity measures. 2. Works collaboratively with internal and external contacts specifically, Physician Services and Hospital Division, across UPMC as well as payors to enhance customer satisfaction and process compliance, ensuring the seamless coordination of work and to avoid a negative financial impact.3. Utilizes 18+ UPMC system and insurance payor or contracted provider web sites to perform prior authorization, edit, and denial services.4. Utilize authorization resources along with any other applicable reference material to obtain accurate prior authorization.
• Retrospective authorization responsibilities1. Resolves basic authorization edits to ensure timely claim filing and elimination of payor rejections and or denials.

High School diploma or equivalent with 2 years working experience in a medical environment (such as a hospital, doctor's office, or ambulatory clinic) OR an Associate's degree and 1 year of experience in a medical environment required. (Bachelor's degree (B.A) preferred) Completion of a medical terminology course (or equivalent) required Skills Required: Knowledge and interpretation of medical terminology, ICD-9, and CPT codesMust be proficient in Microsoft Office applications Excellent communication and interpersonal skillsAbility to analyze data and use independent judgmentSkills Preferred: Understanding of authorization processes, insurance guidelines, third party payors, and reimbursement practicesExperience utilizing a web-based computerized system.

Licensure, Certifications, and Clearances:

• Act 31 Child Abuse Reporting with renewal
• Act 33 with renewal
• Act 34 with renewal
• Act 73 FBI Clearance with renewal

UPMC is an Equal Opportunity Employer/Disability/Veteran