Prior-Authorization Spec (BMG) - Beacon Health System

Reports to the VP Patient Access responsibilities include evaluating designated referred services for authorization needs based on government and commercial payor requirements. Disseminating all clinical and coding supporting documentation to effectively complete the authorization process to ensure appropriate reimbursement. In addition, this position provides exceptional customer service during every encounter with patients, families, visitors and BMG associates by communicating with empathy and clarity regarding the details of the next step in care for the customer.

• MISSION: We deliver outstanding care, inspire health, and connect with heart.
• VALUES: Trust. Respect. Integrity. Compassion.
• SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

Prior Authorization Specialist duties in accordance with established policies and procedures by:

• Serving as primary contact and resource for all designated prior authorization needs.
• Identifying, collecting, and coordinating clinical documentation to support the qualification of ordered services
• Evaluating orders for insurance coverage and authorization requirements.
• Ensuring carrier process requirements are met within contracted guidelines and timeliness.
• Ensuring proper testing is done
• utilizing tools in accordance with the provider's desire and the testing
• criteria and guidelines including both insurance and modality ordering
• guidelines
• Reviewing and complying with additional requests.
• Validating completed authorizations to ensure the authorization corresponds with ordered service, code, time frame and provider.
• Supporting the appeal process by communicating and coordinating resolution expectations with provider and authorization agent.
• Maintaining standardized records to allow for effective coordinating, tracking and reporting of department actions and metrics.
• Advocating for the customer by displaying the ability to recognize when to dispute a non-desirable outcome regarding PA approval (prior authorization).
• Disputing and negotiating, when necessary, on behalf of BHS and the customer for a positive prior authorization outcome.
• Providing exceptional customer centric service during every encounter with patients, families, and associates.
• Using critical thinking skills to make decisions, identify problems, create solutions and helping to implement the change. Escalates concerns when necessary.
• Participating in performance improvement (i.e. follows established work systems, identifies deviations or deficiencies in standards/systems/processes and communicates problems to supervisor or manage
• Prioritizing work in an effective manner.
• Working at a fast pace and maintaining accuracy.
• Understanding the flow and
• rhythm of each task and can connect each resulting convenient, connected
• and coordinated care.
• Using numerous
• software platforms (multiple EMR's, insurance websites, referral database,
• scheduling software, etc.) to conduct tasks for patient care.

Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:

• Assisting others and/or
• accept additional duties.
• Enhancing professional growth and development through in-service meetings and educational programs as approved
• Maintaining up-to-date knowledge and stays abreast of changes and updates as they occur. (Includes but not limited to, Insurance, Department and Processes changes.

Associate complies with the following organizational requirements:

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR), and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:

• Leverage innovation everywhere.
• Cultivate human talent.
• Embrace performance improvement.
• Build greatness through accountability.
• Use information to improve and advance.
• Communicate clearly and continuously.

Education and Experience

• The knowledge, skills and abilities as indicated are normally acquired through the successful completion of an Associate's Degree in Business or Health Care related field and one year medical authorization or related experience; or, in lieu of a degree, completion of a high school diploma or equivalent and three years medical authorization or related experience. Successful completion of an approved Medical Assistant Program with successful completion of the Certification Exam or equivalent medical office experience is preferred. Medical terminology, ICD-10, CPT, prior authorizations, third party payors and prior authorization processes is required.
• Working knowledge of Microsoft Office: Outlook, Excel and Word.

Knowledge & Skills

• Demonstrates well developed communication skills to communicate effectively and
• clearly to a variety of internal and external contacts.
• Demonstrates analytical skills necessary to solve problems and interpret data.
• Promotes collaboration and innovation in the clinical services to ensure an
• interdisciplinary approach to improving healthcare delivery and the
• quality of patient care.
• Must be tactful in handling patient problems often of a highly personal and
• confidential nature.
• Must be able to maintain professionalism during potential frustrating
• interpersonal situations.
• Demonstrates a high knowledge level of procedures, including knowledge of CPT codes
• and ICD-10 Codes.
• Demonstrates a working knowledge (referrals) high knowledge (prior authorization) of
• insurance network guidelines to ensure the referral is scheduled in
• accordance with customer's insurances rules and regulations
• Exhibits a high level of understanding of payor requirements to effectively navigate the authorization process via website, fax or phone.
• Knowledge of insurance and maintains up to date knowledge and stays abreast of changes and updates as they occur.
• Possesses analytical skills necessary to apply knowledge and evaluate clinical information to resolve denials through various, complex levels of appeal.
• Working knowledge of Microsoft Office: Outlook, Excel and Word
• Possesses strong customer service, communication, organizational and analytical skills.

Working Conditions

• Assigned hours within your shift, starting time, or days of work are subject to
• change based on departmental and/or organizational needed.
• May need to travel to other Beacon locations and may be required to work evening hours.
• Working space is frequently congested by other personnel.
• Constantly exposed to noise and distraction.

Physical Demands

• Requires the physical ability and stamina to perform the essential functions of the position.
• Sitting for long periods of time in front of a computer monitor

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