Prior Authorization Rep Sr

JOB DETAILS
Department: Financial Securing
FTE: 1.00 (80 hours per pay period)
Workdays: Monday - Friday
Shift(s): Days/
Shift Length: 8 hours
Location: Remote
*Current List of non-MN States where Hennepin Healthcare is an Eligible Employer: Alabama, Arizona, Arkansas, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Mississippi, Nevada, North Carolina, North Dakota, New Mexico, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin.

Purpose of this position: The Prior Authorization Specialist plays a key role in the patient financial experience by coordinating pre-authorizations for patients and often handling cases that need quick turnaround (e.g., last-minute scheduled services). The individual in this role is an expert on payer regulations and contracts, and they serve as a point of contact for peers looking to resolve questions or issues regarding prior authorizations

RESPONSIBILITIES

• Utilizes online systems, phone communication, and other resources to secure prior authorizations within a timeframe before scheduled appointments/procedures/same day surgeries and during or after care for unscheduled patients
• Verifies medical necessity in accordance with the Centers for Medicare & Medicaid Services (CMS) standards and communicates relevant coverage/eligibility information to the provider/patient, as it pertains to prior authorization
• Coordinates benefits by effectively determining primary, secondary, and tertiary liability when needed
• Obtains pre-certifications and prior authorizations from third-party payers in accordance with payer requirements
• Alerts physician offices to issues with verifying insurance and/or obtaining prior authorizations
• Demonstrates expert understanding of insurance terminology (e.g., co-payments, deductibles, allowances, etc.), and analyzes information received to determine patients’ out-of-pocket liabilities, based on prior authorization status
• Follows up on all prior authorization submissions for timely response
• Follows up on any prior authorization denials; assists Utilization Management with appeals, as needed
• Connects patients with financial counselors, as necessary
• Maintains productivity and quality standards and assists other team members when necessary
• Participates in developing and planning process improvements for the department
• Other duties as assigned
• Complies with all state and federal laws and regulations related to patient privacy and confidentiality

QUALIFICATIONS
Minimum Qualifications:

• High school diploma or equivalent
• 2 years clerical experience in health care revenue cycle operations: billing/claims, patient accounting, collections, admissions, registration, etc. 
• Bilingual strongly preferred, required in some positions 

-OR-

• An approved equivalent combination of education and experience

Preferred Qualifications:

• Experience working in EPIC, preferred

Knowledge/ Skills/ Abilities:

• Requires knowledge of government and commercial payer (Insurance) benefit and eligibility verification, and ability to become aware of and navigate medical policy per payer guidelines
• Demonstrated expertise in logical thinking, data preparation, and analysis
• Comprehensive knowledge of Microsoft Office (Outlook, Word, Excel)
• Strong communication skills, both verbal and written
• Ability to communicate effectively with collaborating departments, providers, and insurance representatives
• Demonstrated organizational skills and the ability to prioritize and manage tasks based on established criteria
• Excellent verbal and written communication and interpersonal skills
• Ability to work independently with minimal supervision, within a team setting and be supportive of team members
• Proficient with Microsoft Office
• Ability to analyze issues and make judgments about appropriate steps toward solutions