Patient Authorization and Referral Representative - Scheduling

Agence PROvidence; Seattle (WA); On-site; USD 45,000 - 65,000; Full time

Job summary

The Prior Authorization Specialist facilitates processing of medication prior authorizations for clinic patients in accordance with established guidelines. This position serves as a liaison between physicians, pharmacies, clinic staff and insurance carriers to assure high quality service to Swedish patients and clinics.

Join Providence Swedish Health Services as part of the Swedish Medical Group family to support medical review processes, claims research, and eligibility verification using Epic

Qualifications

• 2 years experience in a medical clinic or managed care/health insurance plan within the past 2 years.

Responsibilities

• Demonstrates proficiency in core functions of one or more medication prior authorization areas, including prior authorizations, appeals, audits, and training.
• Serves as a resource for the Prior Authorization Service by providing technical assistance to clinic staff and physicians regarding patient coverage, authorization guidelines and procedures, claims research, and departmental operating procedures.
• Utilizes and navigates various insurance company websites to obtain medication prior authorization requirements and protocols.
• Receives, triages, and responds appropriately to phone calls from pharmacies and clinics seeking assistance.
• Processes all documentation and forms related to medication prior authorizations, including submissions via fax, online portals, and telephone.
• Verifies member eligibility as necessary to process medication prior authorizations and collaborates with clinic staff and pharmacies to obtain required information.
• Reviews patient charts to gather documentation supporting the medical necessity of requested medications. Completes prior authorization requests by incorporating relevant clinical information and benefit details, including plan limitations and exclusions, to support the medical review process.
• Contacts clinics to obtain additional clinical information, such as chart notes and diagnostic results, as needed to facilitate the medical review process.

Skills

Prior authorization

Education

Bachelor's degree in a related field

Tools

Epic software

Job description

The Prior Authorization Specialist facilitates processing of medication prior authorizations for clinic patients in accordance with established guidelines. This position serves as a liaison between physicians, pharmacies, clinic staff and insurance carriers to assure high quality service to Swedish patients and clinics.

Providence caregivers are not simply valued - they're invaluable. Join our team at Swedish Health Services DBA Swedish Medical Group and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them.

Duties and Responsibilities:

• Demonstrates proficiency in the core functions of one or more medication prior authorization areas, including prior authorizations, appeals, audits, and training.
• Serves as a resource for the Prior Authorization Service by providing technical assistance to clinic staff and physicians regarding patient coverage, authorization guidelines and procedures, claims research, and departmental operating procedures.
• Utilizes and navigates various insurance company websites to obtain medication prior authorization requirements and protocols.
• Receives, triages, and responds appropriately to phone calls from pharmacies and clinics seeking assistance.
• Processes all documentation and forms related to medication prior authorizations, including submissions via fax, online portals, and telephone.
• Verifies member eligibility as necessary to process medication prior authorizations and collaborates with clinic staff and pharmacies to obtain required information.
• Reviews patient charts to gather documentation supporting the medical necessity of requested medications. Completes prior authorization requests by incorporating relevant clinical information and benefit details, including plan limitations and exclusions, to support the medical review process.
• Contacts clinics to obtain additional clinical information, such as chart notes and diagnostic results, as needed to facilitate the medical review process.

Required Qualifications:

• 2 years experience in a medical clinic or managed care/health insurance plan within the past 2 years

Preferred Qualifications:

• Bachelor's degree in a related field
• 2 years experience in an area such as prior authorizations, medical audits, appeals or delegation
• 1 year Epic software experience

Why Join Providence?

Our best-in-class benefitsare uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our missionof improving the health and wellbeing of each patient we serve.

Accepting a new position at another facility that is part of the Providence family of organizations may change your current benefits. Changes in benefits, including paid time-off, happen for various reasons. These reasons can include changes of Legal Employer, FTE, Union, location, time-off plan policies, availability of health and welfare benefit plan offerings, and other various reasons.