Prior Authorization Specialist

Northside Hospital is award-winning, state-of-the-art, and continually growing. Constantly expanding the quality and reach of our care to our patients and communities creates even more opportunity for the best healthcare professionals in Atlanta and beyond. Discover all the possibilities of a career at Northside today.

A Prior Authorization Specialist is an individual who is highly skilled in ensuring that patients receive the medication that requires pre-authorizations from insurance carriers. These individuals receive prescriptions, address and rectify rejected claims and conduct necessary third party authorization requests.

PRIMARY DUTIES AND RESPONSIBILITIES

1. Interview patients to determine how they can be assisted in receiving authorizations for their medication and procedures.
2. Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed.
3. Develop and implement prior authorization work flow, policies and procedures.
4. Collaborate with other departments to assist in obtaining pre-authorizations in a cross functional manner.
5. Review accuracy and completeness of information requested and ensure that all supporting documents are present.
6. Receive requests for pre-authorizations and ensure that they are properly and closely monitored.
7. Consult with supervisor or nurse manager to obtain clearance that treatment regimen is considered a medical necessity.
8. Process referrals and submit medical records to insurance carriers to expedite prior authorization processes.
9. Manage correspondence with insurance companies, physicians, specialists and patients as required.
10. Look through denials and submit appeals in a bid to get them approved from insurance companies.
11. Create patients’ records and accounts and ensure that pre-authorization information is properly updated in them.
12. Secure patients’ demographics and medical information by using great discretion and ensuring that all procedures are in sync with HIPPA compliance and regulation.

Required:

1. High school diploma, equivalent education (GED) or post-secondary education.  
2. CMA, RMA or three (3) years of related experience.

Preferred:

1. Proficient in EMR.
2. Two (2) years of equivalent experience.
3. Strong, written and verbal communication skills.
4. Ability to project a professional image.
5. Strong knowledge of regulatory standards and compliance requirements, working knowledge of medical business office procedures and basic accounting.
6. Detailed understanding of ICD-9 and CPT.
7. Possess insight into reimbursement and claims procedures.