Job Description

Prior Authorization Specialist- Medical Office Setting

Hybrid Schedule: Columbus, Ohio

Purpose: The OON/Special Coverages/Pre-Certification Financial Clearance Representative (FCR) interacts with patients and/or their representatives to perform insurance verifications, obtain insurance information, and seek authorizations for out-of-network, VA, and BWC appointments and accurately enter and/or update all required data in EPIC. The FCR provides benefit education and financial obligation estimates to patients and collects deposits as necessary.

Requirements: Associates degree or higher, or high school diploma/GED with 2+ years of experience in insurance, healthcare, or related field. Excellent customer service skills coupled with enthusiasm and compassion along with the ability to work in a fast-paced environment. Exceptional verbal and written communication skills. High level of interpersonal skills to handle sensitive, confidential situations and establish effective working relationships with patients, physicians, team members, and others throughout the organization. Attendance, promptness, professionalism, the ability to pay attention to detail, cooperativeness with physicians, co-workers and supervisors, and politeness to customers, vendors, and patients. Ability to escalate issues if necessary. Knowledge and understanding of coding, insurance, and Federal, State, and 3rd party billing/reimbursement requirements. Experience with PC applications including MS Office and Internet. Ability to maintain employer training requirements.

Duties and Responsibilities:

• Uses integrated health information systems and telephone technology with customer service skills to facilitate customer interactions such that the customer experiences the Medical Center and its entities as an accessible, coordinated, and seamless entity.
• Performs an accurate search for patients in EPIC database, thus reducing the number of duplicate patient records. Assesses the patient’s financial ability to pay for services, referring patients to financial counseling staff when appropriate.
• Sends eligibility requests to all payors to verify accurate and current coverage.
• Provides required clinical, insurance, and demographic information to payor to obtain precertification. Verifies insurance eligibility via various tools. Requests and creates referrals for specified population, as required.
• Pre-certifies and obtains authorization numbers and enters information into patient’s account obtaining medical, ICD and CPT codes.
• Contacts external companies to verify patient’s employment and insurance information for Workers’ compensation cases, as required.
• Works with the Veterans’ Administration to ensure services are covered and authorized.
• Provides accurate information to billing and case management to ensure payment of claims.
• Interacts and maintains excellent working relationships with medical staff, referring physicians, and their designees to obtain complete, accurate, timely clinical and financial information required for payer reimbursement.
• Displays the highest level of customer service, attentiveness, and consideration possible in all cases, keeping within the standard set by the Office of Compliance and HIPAA in reference to confidentiality.
• Alerts management of problems with systems and workflow.
• The ability to perform the duties of FCR Pre-Reg and to assist that area as assigned.
• Other duties as assigned.

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