Clinical Authorization Specialist - High Tech Radiology

Trinityhealth; United States; On-site; USD 60,000 - 90,000; Full time

Job summary

Trinity Health Medical Group is seeking a dedicated Prior Authorization Specialist to review and submit medical necessity requests for high-tech radiology services and DME for IHA patients across multiple offices.

You will verify patient histories, contact insurers, obtain authorizations, and monitor status while updating EMR with decisions. The role requires strong knowledge of insurance processes and HIPAA compliance, and may mentor staff.

Qualifications

• Undergraduate degree or Associate's degree in healthcare or graduate of an accredited LPN, PTA, Radiology Technician or Technologist, Respiratory Therapy, Ultrasound or Medical Assistant program.

Responsibilities

• Review, submit, monitor and respond to issues regarding prior authorizations for high-tech radiology services, procedures, and/or DME.
• Communicate professionally with ordering providers, practice staff and insurance representatives.
• Review patient history and tests to identify supporting documentation for testing being ordered.
• Perform data collection and data review tasks as required.
• Contact insurance companies to obtain authorizations.
• Update EMR with approval/denial information and follow up with ordering physician as needed.
• Monitor in-basket, email and fax communications and follow up timely.
• Obtain urgent authorizations the same day or next day.
• Verify correct procedural and diagnostic codes and insurance verification.
• Monitor authorizations/denials and follow up as necessary.
• May mentor other team members and assist with staff training.

Skills

Medical terminology

Insurance processes

Prior authorization

Communication skills

Education

Undergraduate or Associate degree in healthcare

Job description

Employment Type:
Full time Shift:
Day Shift

Description:

Position Description:

Responsible for reviewing, submitting, monitoring and responding to issues regarding medical necessity prior authorizations for high tech radiology services, procedures and/or DME (Durable Medical Equipment) for IHA patients in multiple offices. Reviews patient medical history to identify supporting documentation in the patient chart relevant to the service or procedure; contacts insurance companies and obtains authorization.

Essential Job Functions:

• Responsible for reviewing, submitting, monitoring and responding to issues regarding prior authorizations for high tech radiology services, procedures, and/or DME.
• Professionally communicates (oral or written) with the ordering provider for next steps, practice support staff and representatives of insurance companies.
• Reviews patient medical history, labs, pathology, imaging reports, ED records, consultations, etc. to identify supporting documentation in the patient chart relevant to the testing being ordered.
• Performs data collection and data review assignments as required.
• Contacts insurance companies or appropriate third party and obtains authorizations.
• Updates information in patient medical record (EMR) with approval or denial information; follows up with ordering physician as to status and/or issues with prior authorizations.
• Monitors in-basket, email and fax server if applicable. Follows up on correspondence timely and accurately.
• Obtains urgent authorizations same day, next day.
• Verify correct procedural codes, diagnostic codes and insurance verification.
• Monitors authorizations or denials and follows up, as necessary.
• Contacts insurance companies or appropriate third party and obtains authorizations.
• May act as a mentor to other team members.
• May assist with ongoing training of new and existing staff.
• Supports other offices, attends required meetings and trainings, and participates in committees as requested.
• Performs other duties and participates in special projects, as assigned.

Organizational Expectations:

• Creates a positive, professional, service-oriented work environment for staff, patients and family members by supporting the mission and values of Trinity Health Medical Group.
• Must be able to work effectively as a member of the Call Center team.
• Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management.
• Successfully completes all relevant organizational training and adheres to Trinity Health Medical Group standard of care as outlined in the Trinity Health Code of Conduct.
• Maintains knowledge of and complies with Trinity Health Medical Group standards, policies and procedures.
• Maintains general knowledge of Trinity Health Medical Group office services and in the use of all relevant office equipment, computer and manual systems.
• Maintains strict confidentiality in compliance with Trinity Health Medical Group and HIPAA guidelines.
• Serves as a role model by demonstrating exceptional ability and willingness to take on new and additional responsibilities. Embraces new ideas and respects cultural differences.
• Uses resources efficiently.
• If applicable, responsible for ongoing professional development - maintains appropriate licensure/certification and continuing education credentials, participates in available learning opportunities.

Measured By:

Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position.

Essential Qualifications:

Education:

Undergraduate degree or Associate's degree in healthcare or graduate of an accredited LPN, PTA, Radiology Technician or Technologist, Respiratory Therapy, Ultrasound or Medical Assistant program.

Credentials/Licensure:

• Valid, unrestricted LPN license in the State of Michigan;
• Valid, unrestricted Physical Therapy Assistant license in the State of Michigan;
• Valid, unrestricted Respiratory Therapist license in the State of Michigan;
• Radiology Technician or Technologist Certification;
• Ultrasound Technician Certification; or
• Certification as a Medical Assistant through one of the following certifying agencies:
• American Association of Medical Assistants (CMA)
• American Medical Technologists (RMA)
• National Center for Competency Testing (NCMA)
• National Healthcareer Association (CCMA)
• National Association of Health Professionals (NRCMA)
• American Medical Certification Association (CMAC)

Minimum Experience:

1-3 years' previous clinical experience; 3 to 5 years' experience with insurance referrals, prior authorization or other relevant medical office experience.

Position Requirements (Abilities & Skills):

• Proficient/knowledgeable in medical terminology.
• Proficient knowledge of major health plans and insurance processes.
• Knowledgeable in obtaining medical necessity authorizations for multiple offices.
• Strong knowledge i