Pre-Authorization Coordinator

Job Description

The PAVE Coordinator is responsible for initiating Pre-Authorization requests to the payer for the claims that require approval. This position requires communication with payers, patients, physician offices and hospital clinical staff. This position is primarily responsible for pre-certifying procedures ordered by physicians. The PAVE Coordinator will also be responsible for monitoring appropriateness and medical necessity and providing necessary information for authorization and continued visits.

This individual will confirm pre-certifications that have been obtained or obtain pre-certifications if needed in addition to conducting quality assurance.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Serve as primary resource for LH regarding insurance eligibility, prior authorization process and requirements; collects patient demographic information and coverage information. Advises patients of their financial obligation and collects payments in a courteous and professional manner.

Contacts insurance companies by phone, fax, or online portal to obtain insurance benefits, eligibility, and authorization information.

Updates systems with accurate information obtained; performs quality assurance audits and reports back to leadership opportunities for providing education to patient access.

Responsible for communicating to service line partners of situations where rescheduling is necessary, due to lack of authorization or limited benefits and is approved by clinical personnel.

Ensures that proper authorization is in place for inpatient, elective, outpatient, surgical, urgent/emergent services and is held responsible for timely notification to payers of the patient’s visit to the facility to protect financial standing of the organization. Escalates non-authorized accounts/visits to management.

Ensures all benefits (Copays, Deductibles, Co-Insurance, OOP, LTM), authorizations, pre-certifications, and financial obligations of patients are documented on account, clearly, accurately, precisely, and detailed to ensure expeditious processing of patient accounts and denial prevention.

Maintains a close working relationship with clinical partners, and ancillary departments to ensure continual open communication between clinical, ancillary, and Patient Access & Patient Financial Services, Surgical Scheduling departments, Case Management, and Utilization Review to facilitate the sending of clinical information in support of the authorization to the payer, as assigned.

Monitors team mailbox, e‑mail inbox, faxes, and phone calls responding to all related PAVE account issues, within defined time frames; adheres to the department accuracy and performance standards.

Contact payer to obtain prior authorization. Gather additional clinical and/or coding information, as necessary, in order to obtain prior authorization.

We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances.

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Minimum two (2+) years of experience in Medical Billing, Hospital Patient Access, or Hospital Business Office in an automated setting.

Knowledge of registration, verification, pre-certification, and scheduling procedures.

Experience with Medical and Insurance terminology (ICD-10, CPT
4).

Minimum of one (1+) year of demonstrated strong analytical skills.

Proficiency with Microsoft Office and Outlook.

Excellent verbal and written communication skills.

Preferred experience with the Epic Hospital Billing System.

Associates Degree in Accounting, Finance, Business Administration or Healthcare related field preferred.

Minimum two (2+) years of Revenue Cycle Experience in lieu of degree.

1 or more Certifications preferred:

CRCE - Certified Revenue Cycle Executive

CRCP
- Certified Revenue Cycle Professional

CRCS
- Certified Revenue Cycle Specialist

CHAM – Certified Healthcare Access Manager

CHAA
- Certified Healthcare Access Associate

CHFP
- Certified Healthcare Financial Professional

CRCR
- Certified Revenue Cycle Representative