Senior Authorization Specialist

UPMC; Pittsburgh, Northern (Allegheny County, KY); Hybride; USD 60 000 - 90 000; Plein temps

Résumé du poste

UPMC in Pittsburgh is hiring a full-time Sr. Authorization Specialist to support its Care Management department. This role works Monday through Friday during daylight hours and is eligible to work from home after training, with an on-site rotation about every 5 weeks.

The Senior Authorization Specialist handles authorization activities for inpatient, outpatient, and ED patients, including pre-authorizations, denials, and revenue functions, drawing on extensive payor resources.

Responsabilités

• Maintain compliance with departmental quality standards and productivity measures.
• Collaborate with internal and external contacts to enhance customer satisfaction and process compliance.
• Utilize 18+ UPMC applications and payer websites to perform prior authorization, edit, and denial services.
• Provide on the job training for the Authorization Specialist.
• Use authorization resources to obtain accurate prior authorization.
• Review patient history and medical records to pre-authorize procedures and ensure medical necessity.
• Determine medical necessity using payor criteria and state regulations for a broad service scope.
• Obtain diagnosis, procedure, and service codes to support medical necessity.
• Submit demographics and clinical data to payors for service approvals.
• Provide referral/pre-notification/authorization services to avoid delays.
• Review payments and remittance documents for proper processing of authorization claims.
• Audit data for errors and complete retro-authorizations to resolve denials.
• Research denials and prepare appeals for underpaid or denied claims.
• Submit adjustment requests according to departmental process.
• Identify trends in authorization edits/denials and report to management.

Description du poste

Do you have experience with claims and authorizations? Are you looking to grow your career? UPMC is hiring a full-time Sr. Authorization Specialist to support its Care Management department. This role would work Monday through Friday during daylight hours. This position is eligible to work from home after training, however an on-site rotation is required approximately every 5 weeks.

The Senior Authorization Specialist is to perform authorization activities for a broader scope of inpatient, outpatient, and emergency department patients, as well as denial management and all revenue functions. They will need to demonstrate, through actions, a consistent performance standard of excellence to which all work is to conform. The expertise of the Authorization Specialist Senior shall include an in-depth working knowledge in the area of authorization related activities including pre-authorizations, notifications, edits, and denials across service areas or business units. The Authorization Specialist Senior shall demonstrate the philosophy and core values of UPMC in the performance of duties.

If you are ready to expand your medical experience, this could be the job for you!

Responsibilities:

General Responsibilities

• Maintain compliance with departmental quality standards and productivity measures.
• Work collaboratively with internal and external contacts to enhance customer satisfaction and process compliance, to avoid a negative financial impact.
• Utilize 18+ UPMC applications and payor/ contracted provider web sites to perform prior authorization, edit, and denial services.
• Provide on the job training for the Authorization Specialist.
• Utilize authorization resources along with any other applicable reference material to obtain accurate prior authorization.

Prior Authorization Responsibilities

• Review and interpret pertinent medical record documentation for patient history, diagnosis, and previous treatment plans to pre-authorize insurance plan determined procedures to avoid financial penalties to patient, provider and facility.
• Utilize payor-specific criteria or state laws and regulations to determine medical necessity for the clinical appropriateness for a broad scope of services and procedures considered effective for the patient's illness, injury, or disease.
• Obtain appropriate diagnosis, procedure, and additional service codes to support medical necessity of services being rendered using pertinent medical record and ICD-CM, CPT, and HCPCS Level II resources.
• Submit pertinent demographic and supporting clinical data to payor to request approval for services being rendered.
• Provide referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive administrative time required of providers.

Retrospective Authorization Responsibilities

• Review insurance payments and remittance advice documents for proper processing and payment of authorization claims, as appropriate.
• Audit authorization related data errors and/or completes retro-authorizations to resolve unprocessed or denied claims.
• Research denials by interpreting the explanation of benefits or remittance codes and prepare appeals for underpaid, unjustly recoded, or denied claims.
• Submit requests for account adjustments/controllable losses to manager in accordance with departmental process.
• Identify authorization related edit/denial trends and causative factors, collates data, and provides summary of observations. Communicate identified trends to Manager.