Prior Authorization Specialist

Priority Dispatch Corp.; Cozad (NE); On-site; USD 53,726,000 - 89,544,000; Full time

Job summary

Cozad Community Health System is hiring an entry-level Prior Authorization Specialist at Cozad Community Hospital in Cozad, NE. The role focuses on obtaining prior authorizations for outpatient and inpatient services and monitoring utilization review adherence.

The position requires a high school diploma or equivalent, EHR experience, medical terminology knowledge, and strong time-management skills to ensure timely patient care and compliance with HIPAA guidelines.

Qualifications

• High school diploma or equivalent required.
• Electronic Health Records experience, medical terminology knowledge, computer experience, and ability to examine documents for accuracy required.
• Excellent time management skills with a proven ability to meet deadlines required.

Responsibilities

• Responds to all correspondence from providers and patients regarding prior authorization.
• Submits authorization requests via insurance portals or phone calls; tracks pending requests to ensure timely services.
• Reviews demographic and insurance information in patient accounts and notifies the Business Office of corrections.
• Contacts provider staff when pre-certification is needed and confirms pre-certifications have been obtained.
• Researches and maintains current payor rules by using all resources.
• Establishes efficient methods to ensure medical necessity and appropriate admissions.
• Coordinates with Billing to resolve denials and support concurrent reviews for extended stays.

Skills

Electronic Health Records experience

Medical terminology knowledge

Time management

Communication with patients

Education

High school diploma or equivalent

CPR certification (Basic Life Support)

Tools

EHR systems

Job description

Job DetailsLevel: EntryJob Location: Cozad Community Hospital - Cozad, NE 69130Position Type: Full TimeSalary Range: $18.75 - $31.25 Hourly

Our Mission: To improve the health and well-being of the communities we serve demonstrating compassionate, patient-centered care.

Summary

The Prior Authorization Specialist is responsible for obtaining prior authorization for all outpatient and inpatient services. This position will also monitor adherence to the hospital's utilization review plan to ensure the effective and efficient use of hospital services and monitor the appropriateness of hospital admissions and extended hospitals stays in accordance with the philosophy, goals, and objectives of Cozad Community Health System.

Essential Duties and Responsibilities

This description intends to describe the general nature and level of work performed by employees assigned to this job. It is not intended to include all duties, responsibilities, and qualifications. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Prior Authorization duties:

• Responds to all correspondence from providers and patients with regard to prior authorization.
• Submits authorization requests via insurance portals or via phone calls. Checks on pending requests regularly to ensure patients obtain their services in a timely manner.
• Reviews demographic and insurance information in patient accounts and notifies Business Office when information needs corrected.
• Contacts provider staff when pre-certification is needed for services and confirms pre-certifications have been obtained.
• Researches and maintains current rules, and regulations for insurance payers by utilizing all resources.

Utilization Review duties:

• Establishes and maintains efficient methods of ensuring the medical necessity and appropriateness of hospital admissions are occurring.
• Coordinates, troubleshoots, and resolves identified utilization review problems timely by conducting real time UR meetings.
• Works with the Billing Department to support resolving patient denials based upon appropriate patient status.
• Performs concurrent reviews for patients to ensure that extended stays are medically justified and are also documented in patient's medical records.
• Contacts providers when pre-certification is needed and confirms pre-certifications have been obtained.

General duties:

• Develops and maintains positive working relationships with patients, co-workers, vendors, third-party payor resources, and related entities.
• Researches and maintains current laws, rules, and regulations with billing charges by utilizing all resources.
• Stays current on all Medicare issues, Program Memorandums, Med-Learn matters articles, Change Requests, CPT/HCPCS codes, and other regulatory documents.
• Provides quality healthcare services to all patients.
• Follows all HIPAA guidelines and promotes and ensures patient safety.
• Fulfills mission statement by performing job duties with a high level of customer service while contributing to a positive and professional environment.
• Special projects and other duties assigned.

Supervisory Responsibilities

No supervisory responsibilities.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

High school diploma or equivalent required. Electronic Health Records experience, medical terminology knowledge, computer experience, and ability to examine documents for accuracy required.

Excellent time management skills with a proven ability to meet deadlines required.

Licensure/Certification

Basic Life Support (CPR)

Language Skills

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively with patients, visitors and employees.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this Job, the employee is regularly required to sit; use hands and fingers to handle or feel; reach with hands and arms and talk or hear. The employee is occasionally required to stand and walk. The employee must regularly lift and/or move 10 pounds must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the medical office environment is usually moderate.

Equal Employment Opportunity

Cozad Community Health System is committed to hiring and developing the most qualified employees from the available workforce in the communities we serve.

Equal employment opportunity has been, and will continue to be, a fundamental principle at Cozad Community Health System, where employment is based upon personal capabilities and qualifications without discrimination and retaliation because of veteran status, uniformed service member status, race, color, national origin or ancestry, creed, religion, sex, sexual orientation, gender identity or expression, age, pregnancy (including childbirth, lactation, and related medical conditions), national origin or ancestry, physical or mental disability, genetic information (including characteristics and testing), or any other protected characteristic as established by applicable local, state, or federal law.