Accepting interdepartment applicants only
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
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
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
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
Knowledge & Skills
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.
A minimum of 2 years of related experience