Pre-Authorization Representative I

Highmark Health; Pennsylvania; Hybrid; USD 27,000 - 40,000; Full time

Job summary

Highmark Health in Pennsylvania seeks a Registration/Financial Clearance specialist to obtain prior authorizations from third-party payers and verify patient insurance details. You will collaborate with payer contacts and the clinical team to gather necessary information for authorization and ensure accurate EMR records.

You will adhere to HIPAA and privacy standards, support appeals for denials, and maintain professional communication with patients and payers while handling multiple tasks

Qualifications

• Minimum Associate's Degree Healthcare or Business Administration OR 3 years of related experience in a Healthcare setting
• 1 year with medical terminology and healthcare insurance processes
• Excellent communication and customer service skills
• Proficiency in the use of healthcare information systems
• Ability to prioritize and multitask
• Maintains professional tone at all times when communicating with patients and payer representatives
• Critical problem solving skills
• Experience within financial clearance setting
• Strong attention to detail
• Preferred Patient Access certification
• Revenue Cycle Specialist certification

Responsibilities

• Obtains prior authorizations from third-party payers.
• Keeps current with regulations, policies and process changes.
• Verifies patient insurance and benefits information and exchanges details with contacts.
• Complies with HIPAA and privacy policies.
• Gathers required clinical information from other departments for payer authorization.
• Supports appeal efforts for authorization denials with the business office.
• Maintains authorization records in the EMR.
• Contacts patients to collect demographic and insurance information and updates the EMR.
• Identifies patients needing Medicare ABNs.
• Performs other registration duties as requested.

Skills

Communication skills

Customer service

Medical terminology

Healthcare IT systems

Multitasking

Professional tone

Attention to detail

Education

Associate's degree in Healthcare or Business Administration

Patient Access certification

Revenue Cycle Specialist certification

Job description

Company : Allegheny Health Network Job Description :

GENERAL OVERVIEW: This job is responsible for ensuring that payers are prepared to reimburse AHN for scheduled services in accordance with the payer-provider contract. The representative contacts payers to request service authorization and may collect financial and or demographic information from patients and refers accounts to financial advocates if authorization is not obtained as needed.

ESSENTIAL RESPONSIBILITIES

• Obtains prior authorizations from third-party payers in accordance with payer requirements.
• Remains current on all regulations, policies and procedures and process changes that are essential to completing assigned daily tasks. (50%)
• Verifies patient's Insurance and benefits information. Performs any written and/or verbal communication necessary to exchange information with designated contacts. (15%)
• Complies with HIPAA regulations, as well as the organization's policies and procedures regarding patient privacy and confidentiality. (10%)
• Works with other departments to gather the clinical information required by the payer to authorize services. (5%)
• Works with business office to support appeal efforts for authorization-related denials. (5%)
• Maintains accurate records of authorizations within the EMR. (5%)
• Contacts patients to gather demographic and insurance information as needed, and updates patient information within the EMR. (5%)
• Identifies patients who will need to receive Medicare Advance Beneficiary Notices of noncoverage (ABNs). (5%)
• Performs other registration duties as requested.

QUALIFICATIONS

• Minimum Associate's Degree Healthcare or Business Administration OR 3 years of related experience in a Healthcare setting
• 1 year with medical terminology and healthcare insurance processes
• Excellent communication and customer service skills
• Proficiency in the use of healthcare information systems
• Ability to prioritize and multitask
• Maintains professional tone at all times when communicating with patients and payer representatives
• Critical problem solving skills
• Experience within financial clearance setting
• Strong attention to detail
• Preferred Patient Access certification
• Revenue Cycle Specialist certification

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum: $19.25 Pay Range Maximum: $29.07 Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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Highmark Health is a national, blended health organization that includes one of America's largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network. Based in Pittsburgh, Pa., Highmark Health’s 35,000 employees serve millions of customers nationwide through the nonprofit organization’s affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & community Services. Highmark Health’s businesses proudly serve a broad spectrum of health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.