Role Description

The Prior-Authorization Specialist at Prevea Health is responsible for obtaining and verifying prior authorizations within the appropriate timeline for procedures, diagnostic tests, services, and medications. This role ensures that all requests comply with insurance company policies, guidelines, and healthcare regulations. The specialist will collaborate with healthcare providers, patients, and insurance representatives to obtain the necessary approvals.

• Identify and obtain what is required for preauthorization of procedures, diagnostic tests, services, and medications, seeing the process through completion to minimize denial of claims.
• Coordinate with department providers and staff, coding/billing staff, and insurance representatives to ensure understanding of information needed to obtain proper authorization for payment within the appropriate timelines.
• Review and interpret insurance coverage and policy guidelines to determine authorization requirements.
• Communicate with patients as needed for procedures, diagnostic tests, services, and medications to provide them with information regarding their coverage.
• Accurately document and communicate final determination in the patient's medical record and to appropriate staff, providers, or patient.
• Work with internal teams to identify and address trends or issues in the prior authorization process.
• Provide feedback and recommendations to improve prior authorization workflows and efficiency.

Qualifications

• High School Diploma and/or GED Required
• 1-3 years of experience in a medical or insurance role Required

Requirements

• Display proficient telephone and computer skills with clear and professional speaking abilities.
• Excellent organizational skills.
• Excellent communication skills and follow through with internal and external customers.
• Knowledge of insurance and medical terminology.
• Basic knowledge of current CPT/ICD coding.
• Able to provide exceptional customer service by assessing patient needs, meeting quality standards, and evaluating satisfaction.
• Capable of being empathetic and responsive to patient’s needs by actively listening, asking appropriate questions, and continually looking for ways to provide assistance.
• Able to efficiently multi-task and adapt to fast-paced environments with frequently changing protocols and processes.
• Capable of effectively and positively interacting with staff members throughout the company.
• Promote teamwork and provide a supportive environment throughout the organization.
• Display grammar, spelling, and punctuation knowledge to accurately document patient information.
• Able to work independently and think critically using provided information.

Physical Demands

• Sit - Constantly
• Stand - Rarely
• Walk - Rarely
• Drive - Rarely
• Climb (Stairs/Ladders) - Rarely
• Bend (Neck) - Frequently
• Gross Manipulation (Hands/Arms) - Constantly
• Squat - Rarely
• Twist/Turn (Neck) - Occasionally
• Lift/Carry 0-10 lbs. - Rarely
• Lift/Carry 11-25 lbs. - Rarely
• Lift/Carry 26-35 lbs. - Rarely
• Push/Pull up to 10 lbs. - Rarely
• Push/Pull 11-25 lbs. - Rarely
• Push/Pull 26-35 lbs. - Rarely
• Reach (Above shoulder level) - Rarely
• Reach (Below shoulder level) - Constantly
• Simple Grasping (Hands/Arms) - Constantly
• Fine Manipulation (Hands/Arms) - Constantly
• Gross Manipulation (Hands/Arms) - Constantly

Working Conditions

• Noise - Occasionally

Travel Requirements

• 5%

Hearing Requirements

• Hears Whispers < 3 feet - Constantly
• Hears Whispers 3-8 feet - Constantly

Vision Requirements

• Color Discrimination - Constantly
• Near Vision (Correctable to Jaeger 2 or 20/40 binocular) - Constantly
• Distance Vision (Correctable to Snellen chart 20/40 binocular) - Constantly