Prior Authorization Specialist

Details

Posted: 10-May-24

Location: Ann Arbor, Michigan

Salary: Open

Categories:

Staff/Administrative

Internal Number: 246886

Processes referrals and prior authorizations using established insurance company guidelines. Obtains referrals, authorizations, pre-certifications, prescriptions for therapies, and benefit verification as required. Efficiently manages referral work queues. Responds to patient inquires and manages referral and/or prior authorization related issues in a timely manner. Assists with patient education as it relates to specific requirements of insurance plans. Facilitates scheduling of specialty services and schedules appointments, as necessary. Verifies insurance coverage, collecting, and documenting insurance benefits and authorization requirements and procuring necessary authorizations for medications, medical devices, outpatient services and referrals according to patient insurance protocols. Acts as a subject matter expert in insurance benefits and authorization requirements.

• Knowledge in governmental and commercial payors, medical billing requirements, and prior authorizations.
• Demonstrated knowledge of Prior Authorization operations and medical office and/or hospital procedures.
• Ability to interpret and cascade payor requirements as they relate to insurance prior authorizations.
• Ability to effectively work in both a team environment and independently.
• Ability to establish and maintain effective working relationships with providers, patients, families, and employees.
• Ability to effectively work in a remote environment and connect via multiple communication channels (phone, email, text, etc.).
• Knowledge of how prior authorization functions impact billing, clinical teams, the quality of care and the patient experience.
• Ability to meet and exceed departmental quality, production, and prior authorization standards.
• Ability to review and resolve denials pertaining to Prior Authorizations.
• Ability to suggest workflows that improve efficiency and experience.
• Ability to mentor and motivate a remote team that delivers exceptional customer service via multiple communication channels (phone, email, text, etc.).
• Skill in Microsoft Office.
• Skill in written and oral communication.
• Complete all aspects of the pre-authorization process within required timeframes. Extract pertinent clinical information from the electronic health record, identify ICD-10 and CPT codes for planned outpatient services and provide to payers utilizing payer specific communication protocols; procure all necessary authorizations prior to service.
• Coordinate peer to peer reviews between the servicing provider and medical directors at the insurance company when appropriate.
• Clearly and thoroughly document all actions, contacts, outcomes, and interventions.
• Obtain retro authorizations on billed and rejected claims and denied procedure codes for facility and professional services. Initiate appropriate follow-up actions in response to information obtained and document outcomes for appeals as needed.
• Other duties as assigned.

• Associate degree or combination of High school diploma and 3 years relevant experience is necessary.
• Knowledge of basic medical terminology.
• Must have knowledge of front-end systems (Mi Chart, Cadence, Resolute, Web Denis, M-Connect, I/Observer, etc.) and front-end processes (Check-in, Check-out) including ICD-10 and CPT coding.
• Familiarity with obtaining medical records or professional medical billing financial counseling experience for healthcare patients.
• Individual must exhibit a professional and positive image when interacting with patients, faculty, and staff.
• Must also adhere to high standards of personal and professional conduct, possess excellent customer service, interpersonal, and communication skills, and be able to relate well with people.
• Prior experience performing complex scheduling.
• Financial counseling experience for healthcare patients.
• Exceptional interpersonal skills and ability to work well within a team setting.
• Communicates effectively.
• Demonstrates active listening, written, verbal and information technology skills.

• An associate degree with two years of progressively complex healthcare experience.
• Registration, medical, or surgical specialty clinic and/or insurance experience is preferred.
• Understanding and ability to interpret and communicate insurance benefit information.
• Knowledge and basic understanding of No-Fault Auto, Michigan Assigned Claims, Veteran?s Affairs, governmental and third-party payer rules and regulations is preferred.
• Knowledge of pharmacy formularies and Tier coverage.

This position will be hybrid, days.

Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings.  Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.

Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally.  Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.

Job openings are posted for a minimum of seven calendar days.  The review and selection process may begin as early as the eighth day after posting. This opening may be removed from posting boards and filled anytime after the minimum posting period has ended.

The University of Michigan is an equal opportunity/affirmative action employer.

 

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About University of Michigan - Ann Arbor
A great university is made so by its faculty and staff, and Michigan is recognized as one of the best universities to work for in the country. The Michigan culture is known for engaging faculty and staff in all facets of the university to create a workplace that is vibrant and stimulating.For two consecutive years, the Chronicle of Higher Education has placed U-M in its "Great Colleges to Work For" survey. In particular, the university earns high marks for strong relations between faculty and administrators, a collaborative system of governance, strong pay and benefits, and a healthy work/life balance.
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