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Non Clinical Authorization Lead

Company: West Park Hospital-WY-US
Location: Grand Forks
Posted on: September 13, 2020

Job Description:

Accepting interdepartment applicants only

Job Summary

Under the direction of the Pre-Service Manager and the Pre-Service Supervisor, the Non-clinical Lead contributes to the mission and vision of Altru Health System by contacting all scheduled patients to verify insurance information and ensure pre-authorization and referral requirements are secure.

The pre-service process contributes to reduced patient wait times, improved patient satisfaction, and reduced denials stemming from front-end activities. This staff member reports to the Pre-Service Supervisor and works collaboratively with scheduling, financial counseling, and registration staff members to ensure patient wait times are minimized on the day of service. They are also responsible for ensuring the Referral and authorization management team is meeting their productivity and team goals along with creating and adjusting patient estimates.

Essential Job Functions

Performs pre-authorization and prior authorization for contracted Managed Care programs. Review structured clinical data matching it against specified medical terms and diagnoses or procedure codes (without the need for interpretation) and follow established procedures for authorizing request or referring request for further review. Corresponds with members and providers regarding final pre and prior authorization, coverage limitations, precertification numbers as needed, denial letters regarding disapproved referrals/follow ups, and appeal process assistance. Also, files complete precertification requests as per established procedures.

Investigates and resolves incoming calls and visits from members and providers with questions or concerns about referral management while also providing referral management education to members and providers regarding medical benefits, referral status and prior authorizations. Assists third party payors in the investigation and resolution of member concerns/complaints regarding referral determinations while demonstrating knowledge of contracted referral agreements between Altru Health System and the providers within our network.

Assists with coverage within the Referral and Authorization Management department. Interprets physician orders and referrals to determine service needs.

Reviews referrals and correspondence with the Medical Director and obtains additional medical information for referral determinations from providers/members. Works with Pre-Authorization, Business Office, and Utilization Management regarding referred services and enters/updates all referral information per standard operating procedure. Coordinates external referrals with members, primary care providers, specialty physicians and tertiary care centers.

Contacts insurance organizations to obtain pre and prior authorization for referred services/procedures, gathers medical information to establish medical necessity/appropriateness and relays this information to insurance organizations.

Reviews claims for medical necessity and appropriateness and approves claims or refers for Medical Director review.

Demonstrates knowledge of the Managed Care Information Systems programs for pre-and prior authorization and eligibility purposes, knowledge of state/federal benefits, coverage mandates and related process requirements.

Accurately pre-registers patients into the EPIC system by collecting and recording demographic, insurance, financial, and clinical data in the computer system while also recording and collecting necessary patient account documents.

Creates, maintains, and troubleshoots patient estimates and real time eligibility issues.

Performs other duties as assigned or needed to meet the needs of the department/organization.

Knowledge & Skills

Required:

Demonstrates the ability to effectively communicate both verbally and in written format

Demonstrates knowledge of medical terminology.

Demonstrates ability to process complex instructions translating into logical problem-solving steps.

Preferred:

A minimum of 2 years of related experience

Keywords: West Park Hospital-WY-US, Grand Forks , Non Clinical Authorization Lead, Other , Grand Forks, North Dakota

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