Insurance Authorization Specialist III

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This position is responsible for obtaining authorizations for elective infusions and injections to financially clear patients and ensure reimbursement for the organization. Payor resources and any other applicable reference material such as payor and medical policies should be utilized to verify accurate prior authorization requirements. Escalates financial clearance risks as appropriate in compliance with the Financial Clearance Program. Serving as a liaison between clinical teams and pharmacists ensuring effective communication regarding infusion prior authorization issues. Cases are to be coded, and clinical documentation reviewed to ensure the documentation is complete to maximize reimbursement. MINIMUM QUALIFICATIONS :

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. High school graduate or equivalent with 2 years working experience in a medical environment,

(such as a hospital, doctor’s office, or ambulatory clinic.)
OR

2. Associate’s degree and 1 year of experience in a medical environment.

PREFERRED QUALIFICATIONS :

EXPERIENCE:

1. 3 years’ experience of knowledge and interpretation of medical terminology, ICD-10, and CPT codes.

2. Understanding of authorization processes, insurance guidelines, and third-party payors practices.

3. Proficiency in Microsoft Office applications.

4. Excellent communication and interpersonal skills.

5. Ability to prioritize to meet deadlines and multitask a large work volume with a high level of efficiency and attention to detail.
6. Basic computer skills.

CORE DUTIES AND RESPONSIBILITIES: As an advocate for WVUH/UHA employees, company and departmental goals and initiatives and HR Compliance, demonstrate knowledge of management and employee needs and apply that knowledge to create solutions.

1. Utilize work queues within the EPIC system to manage workloads and prioritize to meet
deadlines.

2. Collect and communicate outpatient benefit information to the Patient Financial Services team

via queues and billing indicators in Epic.

3. Refer to medical and coverage policies for medications.

4. Research CPT codes for drugs/injections.

5. Verify authorization requirements by utilizing insurance portals or calling insurances.

6. Submit authorizations as a buy-and-bill via medical benefit for outpatient on-campus hospital

requests by utilizing insurance portals, prior authorization forms, or calling insurances.

7. Review and interpret medical record documentation to answer clinical questions during the
authorization process.

8. Clearly and effectively communicate with clinics when additional information is needed.

9. Uses hospital communications systems (fax, pagers, telephones, copiers, scanners, and

computers) in accordance with hospital standards.

10. Daily follow up on submitted authorization requests.

11. Scheduling and following up on peer to peers.

12. Submitting and following up with prior authorization appeals for denied medications.

13. Clearly and effectively communicate to the appropriate persons when home infusion or
pharmacy benefit is needed.

14. Verification of referrals and authorizations in work queues.

15. Identify changes in medication dosing/frequency.

16. Assists Patient Financial Services with denial management issues and will obtain retro authorizations as needed.

17. Maintain in baskets in Epic and emails in Outlook.

18. Participate in monthly team meetings and one-on-ones.

19. Builds admissions and submit authorization for elective inpatient chemotherapy admission and
observations.

20. Follows established workflows, identifies deviations or deficiencies in

standards/systems/processes and communica