Prior Authorization Specialist

Vista Healthcare; Saint George (UT); On-site; USD 36,000 - 54,000; Full time

Job summary

Vista Healthcare is seeking a detail-oriented Medical Prior Authorization Clerk in St George, UT. The role involves handling patient and physician calls, entering data into our clinical/non-clinical systems, and reviewing orders against insurance criteria for pre-certification.

You will contact physicians for missing documentation, coordinate with insurers, and keep patients informed on order status and scheduling once approved.

Qualifications

• Six months of prior authorization experience preferred; training provided.

Responsibilities

• Answer calls from patients and physician offices with excellent customer service.
• Enter required information into computer database (clinical and non-clinical).
• Review clinical data and authorize requests for further review per procedures.
• Check orders for insurance coverage; determine if pre-certification is warranted.
• Follow up with physicians for missing documentation to complete orders.
• Pre-certify/authorize procedures with insurers as ordered by the referring physician.
• Communicate updates to ordering physicians when denials occur and assist with peer reviews.
• Inform patients about order receipt and scheduling once insurance is approved.
• Monitor pre-certification status for timely processing.
• Log orders in authorization spreadsheets and schedule procedures when approved.
• Maintain patient confidentiality per regulations.
• Foster effective relationships with staff, providers, and patients.

Skills

Customer service

Medical terminology

Team collaboration

Independent work

Attention to detail

Education

High School Education or GED

Tools

Computer database entry

Job description

Job Details

Job Location: Vista Healthcare Administration - St George, UT 84790, Position Type: Full Time, Job Shift: Any

Essential Functions/Responsibilities:

• Answer calls from patients and physician offices using exemplary customer service skills.
• Accurately enter required information, non-clinical and clinical, into computer database.
• Review clinical data matching it against specified medical criteria and follow established procedures for authorizing request for further review.
• Review incoming orders for completeness to determine if procedure ordered will be covered by insurance (in some cases, pre-certification is not warranted).
• Complete follow-up with physicians for orders still waiting for documentation.
• Contact physicians offices to obtain missing documentation to complete orders.
• Works with patients insurance companies to pre-certify/authorize procedures as ordered by the referring physician.
• Contact ordering physician with update if procedure is denied and assist with scheduling peer to peer reviews, if needed.
• Once order is complete, contact patient to confirm receipt of order and inform patient he/she will receive a scheduling call once insurance has been approved.
• Monitor pre-certification status to ensure timely processing and completion.
• Log order into the appropriate authorization spreadsheet and schedule procedure once approved.
• Maintain patient confidentiality as defined by state, federal and company regulations.
• Establish effective rapport with other employees, professional support service staff, customers, clients, patients, families, and physicians.
• Actively support departmental and corporate strategic plans and ensure successful implementation.
• Maintain cooperative working relationships with all clinics and providers.

Qualifications:

• Six months of previous experience in medical prior authorization. Will train the right person
• Knowledge of CPT and ICD-10 codes.
• Familiarity with medical terminology.
• High School Education or GED.
• Ability to interact with patients, insurers, and office team members in a responsible, professional, and ethical manner.
• Must be able to function effectively in a team-oriented environment.
• Must be able to work independently with limited direction.
• Must be reliable and demonstrate sound judgment and initiative.
• Able to work in a high volume/fast-paced environment.