[Hiring] Prior Authorization Rep Sr @Hennepin Healthcare

Role Description

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.

• 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

• 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.

Requirements

• Experience working in EPIC, preferred.
• 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.