Prior Authorization Specialist at Illinois Bone and Joint Institute LLC

Bourbonnais, Illinois, United States -

Full Time

Start Date

Immediate

Expiry Date

20 Jan, 26

Salary

0.0

Posted On

22 Oct, 25

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Prior Authorization, Medical Terminology, Insurance Processes, Communication Skills, Customer Service, Attention to Detail, Time Management, Problem Solving, Teamwork, EHR Systems, MS Office, Insurance Portals, Dexterity, Confidentiality, Workflow Policies, Medical Necessity Documentation

Industry

Hospitals and Health Care

Description

Description Summary Responsible for obtaining prior authorizations for advanced imaging studies including MRI/CT/Bone Scan/Ultrasound/DEXA, Visco supplementation and other specialty drugs/injectables, EMGs, Spine Injections, Outpatient/Inpatient surgical procedures, DME/Orthotics, other miscellaneous Office-based procedures and referral authorizations for some specialist appointments. Main Objective Secure the prior authorization and notify the requesting party in the timeliest manner possible to ensure the patient can receive the services needed with the least amount of delay. Responsibilities Monitor assigned Epic work queues (WQs) daily. Assign and prioritize the incoming referrals that require evaluation for Prior Authorization by level of urgency to the patient first, then by chronological order. Adhere to workflow policies and protocols for each service. Review details of the Referral ensuring CPT codes and ICD-10 codes are included and match the documentation for services needed within the medical record. Communicate with Clinical Teams on any discrepancies within the Referral. Review Insurance Plan coverage to ensure policy is active prior to initiating the authorization request and Plan requirements for medical criteria are met. Request, track and obtain prior authorization requests and submit medical records via portal or fax to insurance carriers/medical review companies to expedite. Utilize payer portals for the Plans that offer/require online Prior Authorization and phone and fax for others. Manage correspondence with insurance/medical review companies and document all details within the referral and communicate to clinical teams regarding denials or Peer-to-Peer Requests. Retain copies of insurance/medical review correspondence within the patient’s chart. Assist with medical necessity documentation to expedite approvals and ensure appropriate follow-up is performed. Forward approvals to appropriate departments/staff so patients are contacted to schedule appointments. Request, track and obtain retro authorization for denied services. Work with the on-site Financial Advisor or Billing/Coding Team Member for difficult account questions that require resolution. Maintain updates on all Plan’s prior authorization and medical necessity guidelines and communicate changes and trends among Team and with appropriate parties. Safeguard patient information and ensure all information remains confidential. Maintain a high level of productivity and efficiency. Crosstrain on related service lines requiring prior authorization and assist co-workers with WQ assignments. Depending on role, assist in the collection of surgical down payments as needed. Depending on role, assist patients with questions on co-insurance, deductible and out-of-pocket expenses. The job holder must demonstrate competencies applicable to the job position. Requirements Requirements High school diploma or GED. Associate degree in business/communication/healthcare field preferred. Minimum of 2 years administrative / clinical experience in a health care setting. Available to work 8:00am - 4:30pm shift Knowledge of medical terminology and insurance processes strongly preferred. Excellent verbal and written communication skills. Exceptional customer service skills and the ability to maintain professionalism and interact well with patients, staff, and vendors. Highly computer literate with capability in EHR and PM systems, MS Office, Insurance portals, databases and related business and communication tools and software. Strong attention to detail and the ability to accurately follow instructions with minimal oversight. The ability to exercise independent judgment, decision making, and problem solving. Strong time management skills. Need to be able to work on tight timelines for last minute add-on tests and procedures. Ability to work effectively in a team environment. Physical/Mental Demands: Work may require hand dexterity for office machine operation. This is a desk-based position so there is sitting for extended periods of time. Manual dexterity for using a computer keyboard. Headsets and speaker phones are available. Environmental/Working Conditions: Work is performed in an office environment. Involves frequent contact with staff, patients, and the public. Work may be fast paced and stressful at times. Base salary offers for this position may vary based on factors such as location, skills and relevant experience. We offer the following benefits to those who are benefit eligible (30+ hours a week): medical, dental, vision, life and AD&D insurance, long and short term disability, 401k program with company match and profit sharing, wellness program, health savings accounts, flexible savings accounts, ID protection plan and accident, critical illness and hospital benefits. In addition, we offer paid holidays and paid time off.

Responsibilities

The Prior Authorization Specialist is responsible for obtaining prior authorizations for various medical services and ensuring timely notifications to the requesting parties. This role involves monitoring work queues, reviewing referrals, and managing correspondence with insurance companies.