Prior Authorization Specialist

POSITION SUMMARY

Responsible for understanding the use and treatment of biologic medications. Works directly with patients to educate them on the use and procedures. Provides insurance companies, pharmacies and patients with required information in regards to obtaining authorization for the medication. Maintains and organizes lists of patients enrolled in the treatment of biologic medications. Ability to multi task, must be extremely organized and detail oriented.

• Assists in the data entry and completion of Authorization forms and notifications. Obtains insurance prior authorization for patients and re-authorization for additional treatments.
• Ensures insurance carrier documentation requirements are met and Authorization documentation is scanned and documented in the patient's medical record.
• Appeals denials and/or sets up peer to peer reviews.
• Medication Prior Authorization. Receive all requests for medication prior authorizations from pharmacies. Identify the appropriate form needed. Provide documentation to support the use of the medication by researching the medical record. This will require knowledge of medication classifications, side effects documentation, and dosage documentation. Communicate via fax or online to the insurance company.
• Communicates with specialty pharmacy to order new Biologic Rx, Update dose and frequencies and schedules deliveries.
• Utilizes resources through manufacturer to obtain authorization.
• Schedules patient appointments for initial injection and provides instruction for follow up treatment
• Maintains and organizes lists of patients enrolled on Biologics. Updates insurances and renewals on time in order to obtain medications.
• Communicates orders to infusion centers when applicable.

ESSENTIAL FUNCTIONS

Clerical

• Scheduling appointments
• Reports malfunctioning equipment to appropriate personnel.
• Demonstrates awareness of protocol for malfunctioning equipment and repair

Medical records management

• Follows established processes to obtain, manage and utilize patient information to enhance and improve individual and organizational performance in patient care.
• Provides for confidentiality, integrity and security of medical records.

Communication

• Listens respectfully, gives feedback directly, honestly and talks with others to clarify differences.
• Utilizes translation services when needed.
• Utilizes appropriate services when needed to communicate with employees and patients with speech and hearing disorders.
• Effectively communicates and interacts with patients, their family, and other external and internal clients (including fellow employees) from diverse backgrounds.

Quality

• Demonstrates a willingness to look at new ideas and work in a changing environment.
• Understands, verbalizes and participates in the quality improvement process.
• Supports initiatives designed to improve individual and organizational performance.

Access Control

• Protected Health Information (PHI): Serves and protects the physician or health care provider practice by adhering to professional standards, policies and procedures, federal, state, and local requirements, and HIPPA.
• Additional security is outlined in the Access Control Policy by job role and can be located Company Intranet.

Other

• Other duties as assigned.

KNOWLEDGE, SKILLS AND EXPERIENCE

Minimum Education (or substitute experience) required:

• High School diploma or GED

Minimum Experience required:

• Minimum one (1) year experience in computerized appointment scheduling.

• Two year's medical clerical experience preferred. Good communication and language skills required.

Skills/Knowledge/Abilities

• Ability to type 40 wpm, use standard office equipment and be computer literate.
• Knowledge of medical terminology, health care environment and patient processing with computerized scheduling software. Knowledge of outpatient surgery forms, policies and procedures.

Interpersonal: Client oriented. Actively participates in the development of a healthy work environment. Uses interpersonal skills to establish and maintain healthy interpersonal relations,

Current Openings for Prior Authorization Specialist Jobs at Sacramento Ear, Nose & Throat