Pre Authorization Representative

Mercy Medical Center; United States; Presencial; USD 42.000 - 64.000; Jornada completa

Descripción de la vacante

Mercy Medical Center is seeking a detail-oriented preauthorization specialist to ensure medical necessity and proper utilization of health care resources. You will manage authorizations across tests, procedures, and medications, verifying insurance benefits and coordinating with providers.

The role emphasizes accurate documentation, adherence to ICD-10 coding standards, and timely communication with patients and clinicians to resolve denials and obtain approvals.

Formación

• High school diploma or equivalent required.
• Experience in medical billing or healthcare administration preferred.
• Knowledge of ICD-10 coding and preauthorization processes required.
• Excellent communication and multi-tasking abilities.

Responsabilidades

• Perform pre-authorization duties for tests, procedures, and medications.
• Obtain authorizations and assess medical necessity.
• Review requests for alignment with criteria.
• Verify patient insurance benefits and eligibility.
• Prepare and submit documentation to insurers.
• Understand ICD-10 LMPR, NCD and pre-authorization guidelines.
• Maintain records of authorizations, approvals, denials, and follow-ups.
• Resolve denied authorizations and resubmit as needed.
• Monitor AI 278 EDI transactions for attached records and approvals.
• Communicate with providers and patients; initiate waivers when denied.
• Call patients with cost and denial reasons.
• Use call manager and computer for duties.
• Follow safety guidelines.

Conocimientos

Interpersonal skills

Customer service

Written communication

Oral communication

Multitasking

Educación

High School Diploma or equivalent

Associates degree or HIM certification preferred

RHIT or RHIA certification preferred

Herramientas

EDI transactions monitoring

Preauthorization systems

Descripción del empleo

Work Shift Day Scheduled Weekly Hours 40

Summary This position supports Mercy's philosophy of patient centered care by possessing a complete understanding of health insurance industry requirements for preauthorization to ensure medical necessity and appropriateness of delivery of health care resources provided to members as per their benefit package.

Job Description

Job Duties

• Performs pre-authorization duties requiring good knowledge of hospital programs and procedures.
• Will obtain authorizations for test, procedures and medications, review for medical necessity and if meets criteria.
• Review Request: Assess prior authorization request for various medical services, procedures, and medications to determine if they meet the necessary criteria for approval.
• Verify Insurance: Confirm patient insurance benefits and eligibility, ensuring that the proposed services are covered under their plan.
• Possesses a complete understanding of health insurance industry requirement for preauthorization per payer.
• Documentation: Prepare and submit detailed authorization requests to insurance companies, including all required documentation to support the request.
• Understandings ICD-10 coding systems for local medical review policies (LMRP), national coverage determination (NCD) and pre-authorization process required.
• Record Keeping: Maintain accurate records of all prior authorization requests, documenting approvals, denials, and follow-up actions.
• Problem Solving: Investigate and resolve issues related to denied authorizations, including resubmitting requests and appealing decisions when necessary.
• Monitor AI 278 EDI transactions to ensure Records are attached and approvals are received before services are rendered.
• Interacts with providers/clinical teams for any additional documentation needed.
• Appeals denials and communicate with clinical team on the status of the appeal and if a peer to peer need to be done.
• Documents all information for the office to call on a peer to peer.
• Communication: Act as a liaison between patients, healthcare providers, and insurance companies, effectively communicating the status of authorization requests and any necessary follow-up actions.
• Initiates waivers when services are denied.
• Calls patient or guarantor to explain and gives cost of test/procedure and reason for denial.
• Uses the call manager and computer to perform all pre-authorization and scheduling duties.
• Follows Mercy's safety guidelines, carries out job‑specific safety duties and responsibilities, and promptly reports any unsafe conditions, situations, incidents and injuries.

Knowledge, Skills and Abilities

• Basic proficiency in operation of computer, basic keyboarding, fax machine, filing systems, and telephone systems or call center knowledge.
• Knowledge of medical terminology, anatomy strongly preferred.
• Knowledge of ICD-10 coding systems for local medical review policies (LMRP), national coverage determination (NCD) and pre-authorization process required.
• Excellent interpersonal and customer service skills.
• Excellent oral and written communication skills.
• Ability to perform multiple tasks with constant interruptions.

Professional Experience

• Proficiency in Medical Terminology and coding (CPT and ICD-10) is essential for accurately processing requests.
• Previous experience in medical billing, healthcare administration, or a related field is typically required.
• Communication Skills: Strong verbal and written communication skills are necessary for effective collaboration with healthcare providers and insurance representatives The ability to navigate complex situations and resolve issues for authorizations.

Education

• High School Diploma or equivalent strongly preferred.
• Relevant experience to be considered in lieu of degree.
• Preferred: Associates degree, graduate of HIM program, RHIT or RHIA certification.

Licensure, Certification, Registration

None required.

Physical Requirements

Sedentary: Exert up to 10 lbs. of force occasionally and/or a minute amount frequently.

Pay Rate Type Hourly

Mercy is an independent, community‑based organization supporting the Cedar Rapids area for over 120 years.

Mercy is an equal‑opportunity employer. We value diversity, equity, and inclusion and therefore evaluate qualified applicants without regard to race, color, ethnicity, ancestry, sex, sexual orientation, gender identity, marital status, civil union status, parental status, religion, national origin, age, disability, veteran status, and other legally protected characteristics.