PAS PSO Prior Authorization Specialist III WMCG

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Day (United States of America)

The Patient Access Services (PAS) Prior Authorization Specialist III position reports to the PAS Manager of Pre-Service Operations and is responsible to secure accounts by performing a combination of insurance verification to gather benefit information if not already obtained and validating prior authorization has been initiated with the payer before services are rendered. This position works with physicians, nurses, clinic managers and financial advocates to resolve issues that arise during the prior authorizations process.

This position may also support Pre-Registration including preparing patient estimates. Maintain established productivity benchmarks and meets goals in a fast-paced environment. Other duties as assigned.

Quality/ Safety

• Works in conjunction with Insurance Verification Specialist to verify insurance eligibility, benefits, network status and creates pre-service liability estimate.
• Ensures accurate ICD, CPT codes and related medical records are submitted in the authorization request.
• Secures prior authorizations for scheduled and nonscheduled services.
• Acts as a liaison between the payer and clinic schedulers/medical support staff.
• Follows up on delayed or denied authorization requests and escalates for resolution.
• Creates detailed documentation and maintains/stores the authorization paper/electronic trail.
• May work in the work queues to resolve claims denials related to the prior authorization.
• Perform other work-related duties as requested/directed by management.
• Observes work hours and provides proper notice of absences, tardiness, or work schedule changes.
• Maintains courteous and cooperative working relationships with WHS management, patients, physicians, other professional contacts, and the public. Demonstrates ability to tactfully handle difficult situations.
• Presents a well-groomed and professional image.
• Documents thorough explanatory notes on patient accounts, concerning any non-routine circumstances, clarifying special billing processes.
• Maintains a working knowledge of available information system capabilities and performs all system applications that are required.
• Understands and applies WHS philosophy and objectives, and PAS policies and procedures, as related to assigned duties. Understands the admission, outpatient and emergency registration process.
• Maintains confidentiality of patient information, in accordance with WHS policy and HIPPA regulations.
• Consistently demonstrates the ability to organize work, recognizes and establishes appropriate work priorities, and completes work in a productive manner, without creating backlogs.
• Maintains proficiency in data entry skills.
• Assists physicians and their office staff to expedite scheduling, pre-admission, Medicaid screening and pre-certifications on all accounts.
• Resolves errors and applicable Claim, DNB and Patient Work Queues.
• Performs other duties as assigned.

Budget/Financial

• Attempts to collect the estimated self-pay balance of all inpatient, outpatient and ER accounts, at the earliest possible collection control point.
• Monitors in-house accounts and attempts to make financial arrangements with guarantors for payment of their self-pay balances in full and prior to discharge.
• Completes financial evaluation forms to document guarantors' income, expenses, assets and liabilities.
• Identifies those patients without adequate insurance coverage. Makes personal contact with patient or guarantor to determine guarantor's ability to pay non-covered charges, as well as to determine potential eligibility for financial assistance programs (namely Medicaid).
• Maintains a list of health care financial assistance programs and the eligibility requirements for each program. Refers patients/guarantors to sources of outside funding assistance, as needed.
• Works efficiently and accurately within designated time frames to ensure a continuity of information and cash flow.
• Contacts scheduled patients at home to obtain…