Are you passionate about ensuring that patients receive the care they need? Do you thrive in a fast-paced environment where attention to detail is crucial? If so, we want you to be part of our team as an Authorization Specialist at UPMC Hillman Cancer Center!
At UPMC, we’re committed to providing exceptional oncology care to our community. As an Authorization Specialist, you’ll play a vital role in ensuring that patients have access to the care they deserve. Our team is dedicated to excellence, and we’re looking for someone who shares our commitment to making a difference.

KEY RESPONSIBILITIES:

• Manage denials and oversee all revenue functions.
• Demonstrate a high standard of excellence in all work.
• Utilize expertise in authorization-related activities, including pre-authorizations, notifications, edits, and denials.

RESPONSIBILITIES:

• Prior authorization responsibilities:
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• Reviews and interprets medical record documentation for patient history, diagnosis, and previous treatment plans to pre-authorize insurance plan determined procedures to avoid financial penalties to patient, provider and facility.

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• Utilizes payor-specific approved criteria or state laws and regulations to determine medical necessity or the clinical appropriateness for inpatient admissions, outpatient facility, office services, durable medical equipment, and drugs in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury, or disease.

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• Ensures accurate coding of the diagnosis, procedure, and services being rendered using ICD-9-CM, CPT, and HCPCS Level II.

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• Provides referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive nonclinical administrative time required of providers.

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• Submits pertinent demographic and supporting clinical data to payor to request approval for services being rendered.

• General responsibilities:
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• Maintains compliance with departmental quality standards and productivity measures.

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• Works collaboratively with internal and external contacts specifically, Physician Services and Hospital Division, across UPMC as well as payors to enhance customer satisfaction and process compliance, ensuring the seamless coordination of work and to avoid a negative financial impact.

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• Utilizes 18+ UPMC system and insurance payor or contracted provider web sites to perform prior authorization, edit, and denial services.

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• Utilize authorization resources along with any other applicable reference material to obtain accurate prior authorization.

• Retrospective authorization responsibilities:
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• Resolves basic authorization edits to ensure timely claim filing and elimination of payor rejections and or denials.

• High School diploma or equivalent with 2 years working experience in a medical environment (such as a hospital, doctor’s office, or ambulatory clinic)
• OR an Associate’s degree and 1 year of experience in a medical environment required. (Bachelor’s degree (B.A) preferred)
• Completion of a medical terminology course (or equivalent) required
• Knowledge and interpretation of medical terminology, ICD-9, and CPT codes required
• Must be proficient in Microsoft Office applications
• Excellent communication and interpersonal skills
• Ability to analyze data and use independent judgment
• Understanding of authorization processes, insurance guidelines, third party payors, and reimbursement practices preferred.
• Experience utilizing a web-based computerized system preferred.