Prior Authorization Coord

Summary:
Under the general supervision of the Business Manager responsible for the integrity of each Comprehensive Cancer Center (CCC) location insurance prior authorization process. Coordinates and arranges for all for drug orders chemotherapy infusions Hem/Onc infusions radiology orders follow-up patient referrals ensuring day hospital patient financial clearance from insurance companies have been received as well as possible trouble shooting as needed. Has a clear knowledge of Current Procedural Terminology (CPT) International Classification of Diseases (ICD) and registration information. Analyzes and provides process improvement updates and/or recommendations to the department manager.

 

Responsibilities:
Collaborates with physicians and mid-level providers to schedule peer-to-peer discussions to obtain prior authorization of services denied by the patients insurance.



Ensures that all physician orders are complete legible and scanned within the electronic medical record for viewing



Arranges for and obtains all appropriate documentation from referring physician for Day Hospital patients.



Conducts Peer to Peer discussions between the insurance Medical Director and Provider.



Coordinates all information for managing insurance denials.



Regularly participates in business team meetings with staff and management to make recommendations where there are perceived problems.



Reviews variety of reports and records to ensure that referrals and pre-authorizations from insurance companies have been received; also reviews for appropriate authorization to notify registration. Ensures staff is made aware of changes in hospital or third party procedures; ensures appropriate training and adherence to approved policies and processes directly or through supervisory staff.



Confirms patient eligibility with insurance carriers and obtains visit authorizations as necessary.



Provides mature quality customer service to patients their families and /or their representatives.



When necessary contacts agencies outside the hospital to obtain pertinent patient information and to coordinate clinic/treatment programs.



Contacts third party payers to obtain required pre-authorizations in accordance with established policies.



Returns phone calls to patients physician offices and other medical providers including but not limited to laboratory and radiology facilities.



Collaborates with various Lifespan personnel in order to resolve billing issues prior-authorizations denials and insurance denials/write-offs.

 

Other information:
BASIC KNOWLEDGE:

High School diploma or equivalency required. Level of knowledge of business systems office procedures and computer database and basic computer skills normally acquired through completion of one year post-secondary business program or the equivalent.



Possess strong medical terminology knowledge.



Strong organizational skills to effectively plan direct and manage high volume of orders requiring prior authorization.



Interpersonal skills to train and coach staff and to demonstrate effective customer relations and communications with others within and outside the Hospital.



Analytical skills to evaluate effectiveness of work flow make recommendations for change and to develop review and evaluate various records and reports.



Ability to operate personal computer including keyboard skills and familiarity with computer networks.



Clerical skills to demonstrate and/or perform activities with CCC staff and providers.



Ability to recognize and understand clinical documentation pertinent for obtaining prior authorizations.



EXPERIENCE:

Two years progressively responsible experience in health care with a heavy emphasis in one or more of the following areas: patient care environment healthcare operations database management documentation and departmental operations. Knowledge of coding in a healthcare environment is a plus.



Excellent analytical and critical thinking skills and a focus for detail is needed.



WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS:

Work is performed in a normal office environment.



SUPERVISORY RESPONSIBILITY:

None.

 

Lifespan is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status.   Lifespan is a VEVRAA Federal Contractor.

 

Location: The Miriam Hospital USA:RI:Providence

 

Work Type: Per Diem

 

Shift: 1

 

Union: Non-Union