Idaho Gastroenterology Assoc
Prior Authorization Coordinator
Idaho Gastroenterology Assoc - Meridian, Idaho, us, 83680
Work at Idaho Gastroenterology Assoc
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Overview
Description
JOB DESCRIPTION:
Prior Authorization Coordinator
(RN/LPN/MA)
REPORTS TO:
Site Administrator
DEFINITION OF POSITION:
A clinic prior authorization coordinator job involves reviewing requests for medical treatments, services, or procedures to determine their need for insurance prior authorization prior to the procedure being conducted or the medication prescribed being obtained. The prior authorization nurse coordinator will be primarily responsible for conducting and completing necessary third-party prior authorization requests for high-cost medications; however, as time allows, they will process all other prior authorization requests in the prior authorization order list. The prior authorization coordinators verify patient eligibility, gather necessary information, and submit requests for pre-authorizations to insurance companies for medical treatments and procedures. They also monitor and track authorization status, communicate with providers and patients, and ensure adherence to guidelines and timeframes. Other areas of responsibility include pre-screening patients for viable payment sources, managing reimbursement issues associated with high-cost injectable medications, identifying opportunities for improving reimbursement from payers, and conducting retrospective utilization reviews on cases of payment denials or insufficient reimbursement.
A wide variety of internal and external relationships are inherent to the success of this position. The incumbent interacts with IGA employees on multiple levels, including physicians, advanced practice providers, medical/clinical staff, billing department personnel, and coding staff. External contacts include third-party payers, governmental peer review organizations, and referring physicians. Strong communication skills, problem-solving abilities, and professional presentation are imperative, along with an ability to be innovative and creative. To be effective, this position must be able to establish collaborative working relationships.
ESSENTIAL RESPONSIBILITIES: 1. Review medical records for up-to-date problem list, including patient-reported medication and allergies and diagnoses that are documented by physicians or providers. Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed. 2. Collaborate with all departments to assist in obtaining prior authorizations. 3. Receive requests for prior authorizations and ensure that they are properly and closely monitored. 4. Request, track and obtain pre-authorization from insurance carriers within time allotted for diagnostic, pharmaceutical therapy, and medical therapy services. 5. Follow prior authorization workflow and policies, and procedures. Key elements are noted below: a. Prior Authorization, Insurance Verification, and Submission: Reviewing patient information, verifying eligibility, and submitting prior authorization requests to insurance companies. i. Determine if all required previous treatment methods have been completed prior to submitting new authorization requests. ii. Review the accuracy and completeness of information requested and ensure that all supporting documents are present. iii. Ensure the patient's insurance is still effective. iv. Complete prior authorization forms, online portal documents, or conduct verbal authorizations when required. v. Patient Assistance programs will be explored to support both financial impact to the patients as well as the clinic. Enroll patients where available. vi. Coordinate with the billing department to support patients with high out-of-pocket financial impacts. vii. Process referrals and submit clinical supporting documentation to insurance carriers to expedite prior authorization processes. b. Communication: Communicating with patients, providers, hospitals, diagnostic facilities, and insurance carriers during authorization cycle. i. Manage correspondence with insurance companies, physicians, and patients as required. ii. Communicating with providers and patients regarding authorization status and any necessary follow-up. iii. Advocate for Patients: Represent patient needs and ensure they receive appropriate, timely, and effective care while adhering to insurance policies. c. Documentation, Tracking, and Monitoring: Tracking the status of authorization requests and ensuring timely processing. i. Document all prior authorization information, including approval dates, prior authorization number in patient profile. ii. Maintaining accurate records of all communication and actions related to authorizations. iii. Proactively work on prior authorizations that are due to expire. iv. Look through denials and submit appeals if requested by physician to get them approved from insurance companies. d. Adherence to Guidelines: Following established criteria, timeframes, and policies for prior authorization. e. Problem Solving: Addressing any issues or questions that arise during the authorization process. f. Provide Education: Educate patients, providers, and staff on prior authorization processes, eligibility requirements, and appeal procedures. 6. Will be responsible to monitor and improve associated key performance indicators.
TEAM MEMBER OBJECTIVE: 1. Secure patients' demographics and medical information by using great discretion and ensuring that all procedures are in sync with HIPAA compliance and regulations 2. Operate online insurance verification websites. 3. Understand that the stress of illness may alter patient behavior and ability to follow through on plan of health care; interact with respect, including situations where patient and/or family display anger or distress. 4. Promote patient welfare and independence by communicating through words and actions and understanding of patients' reactions to the healthcare environment. 5. Relay information from the patient to the Provider. 6. Index documents in the patient's electronic record as needed. 7. Communicate the need for additional records that would support patient treatment to medical records or obtain them directly when accessible through IHDE. 8. Comply with patient satisfaction, customer service, and ambulatory care standards. Demonstrates respect for IGA policies for security, privacy, and confidentiality while using IGA equipment. Follows personnel policies within the IGA personnel manual 9. Maintain HIPAA compliance (patient privacy). Adhere to National Patient Safety goals. 10. Assist with quality improvement projects. 11. Demonstrate proficiency in use of the computer for all aspects of patient care and documentation including electronic medical records, other healthcare applications used, and Microsoft Office. 12. Assist with keeping the staff lounge neat. 13. Utilizes Microsoft Outlook email for all non-patient correspondence. 14. Immediately report any network, hardware, or software malfunction to the IT Officer or Supervisor. 15. Complete all required competencies and maintain skill level. 16. Recognize the need for continuous learning by attending staff development programs and workshops. 17. Serve on task forces/committees as requested. 18. Perform other duties as assigned.
REQUIRED SKILLS, KNOWLEDGE, AND ABILITIES Knowledge of medical terminology Knowledge of insurance guidelines and authorization requirements Strong Attention to detail, as accuracy is crucial for ensuring correct information is submitted and that authorizations are obtained appropriately Demonstrated customer-first attitude and philosophy Ability to learn computer and application skills as applicable to role Ability to interact with and work around people Ability to make judgments in demanding situations Ability to react to frequent changes in duties and volume of work Effective oral and written communication skills Ability to listen empathetically Ability to logically organize details Ability to manage multiple concurrent activities Knowledge of interpersonal communications in a complex organization Commitment to respectful patient and family-centered care Commitment to respectful treatment of all colleagues Commitment to patient privacy Commitment to patient safety QUALIFICATIONS:
Registered Nurse (RN) or Licensed Practical Nurse License: A current and valid RN/LPN license is required. Graduate of Medical Assistant Program Certified Medical Assistant preferred Maintains Basic Life Support certification
PHYSICAL REQUIREMENTS: • Full Range of body motion, including handling and lifting patients • Requires working under stressful conditions and requires standing and walking for extended periods of time. • Exposure to communicable diseases and/or bodily fluids • Ability to safely and successfully perform the essential job functions consistent with the ADA, FMLA and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards. • Ability to maintain regular, punctual attendance consistent with the ADA, FMLA, and other federal, state and local standards. • Must be able to lift and carry up to 50 lb.
POTENTIAL EXPOSURE TO BLOOD AND BODILY FLUID:
(Please check the appropriate category below)
Category 1 - Performs tasks which involve exposure to blood, body fluid, or tissue. X
Category 2 - Performs tasks which involve no exposure to blood, body fluid, or tissue, but may perform unplanned Category 1 tasks.
Category 3 - Performs tasks that involve NO exposure to blood, body fluid, or tissue
JOB DESCRIPTION:
Prior Authorization Coordinator
(RN/LPN/MA)
REPORTS TO:
Site Administrator
DEFINITION OF POSITION:
A clinic prior authorization coordinator job involves reviewing requests for medical treatments, services, or procedures to determine their need for insurance prior authorization prior to the procedure being conducted or the medication prescribed being obtained. The prior authorization nurse coordinator will be primarily responsible for conducting and completing necessary third-party prior authorization requests for high-cost medications; however, as time allows, they will process all other prior authorization requests in the prior authorization order list. The prior authorization coordinators verify patient eligibility, gather necessary information, and submit requests for pre-authorizations to insurance companies for medical treatments and procedures. They also monitor and track authorization status, communicate with providers and patients, and ensure adherence to guidelines and timeframes. Other areas of responsibility include pre-screening patients for viable payment sources, managing reimbursement issues associated with high-cost injectable medications, identifying opportunities for improving reimbursement from payers, and conducting retrospective utilization reviews on cases of payment denials or insufficient reimbursement.
A wide variety of internal and external relationships are inherent to the success of this position. The incumbent interacts with IGA employees on multiple levels, including physicians, advanced practice providers, medical/clinical staff, billing department personnel, and coding staff. External contacts include third-party payers, governmental peer review organizations, and referring physicians. Strong communication skills, problem-solving abilities, and professional presentation are imperative, along with an ability to be innovative and creative. To be effective, this position must be able to establish collaborative working relationships.
ESSENTIAL RESPONSIBILITIES: 1. Review medical records for up-to-date problem list, including patient-reported medication and allergies and diagnoses that are documented by physicians or providers. Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed. 2. Collaborate with all departments to assist in obtaining prior authorizations. 3. Receive requests for prior authorizations and ensure that they are properly and closely monitored. 4. Request, track and obtain pre-authorization from insurance carriers within time allotted for diagnostic, pharmaceutical therapy, and medical therapy services. 5. Follow prior authorization workflow and policies, and procedures. Key elements are noted below: a. Prior Authorization, Insurance Verification, and Submission: Reviewing patient information, verifying eligibility, and submitting prior authorization requests to insurance companies. i. Determine if all required previous treatment methods have been completed prior to submitting new authorization requests. ii. Review the accuracy and completeness of information requested and ensure that all supporting documents are present. iii. Ensure the patient's insurance is still effective. iv. Complete prior authorization forms, online portal documents, or conduct verbal authorizations when required. v. Patient Assistance programs will be explored to support both financial impact to the patients as well as the clinic. Enroll patients where available. vi. Coordinate with the billing department to support patients with high out-of-pocket financial impacts. vii. Process referrals and submit clinical supporting documentation to insurance carriers to expedite prior authorization processes. b. Communication: Communicating with patients, providers, hospitals, diagnostic facilities, and insurance carriers during authorization cycle. i. Manage correspondence with insurance companies, physicians, and patients as required. ii. Communicating with providers and patients regarding authorization status and any necessary follow-up. iii. Advocate for Patients: Represent patient needs and ensure they receive appropriate, timely, and effective care while adhering to insurance policies. c. Documentation, Tracking, and Monitoring: Tracking the status of authorization requests and ensuring timely processing. i. Document all prior authorization information, including approval dates, prior authorization number in patient profile. ii. Maintaining accurate records of all communication and actions related to authorizations. iii. Proactively work on prior authorizations that are due to expire. iv. Look through denials and submit appeals if requested by physician to get them approved from insurance companies. d. Adherence to Guidelines: Following established criteria, timeframes, and policies for prior authorization. e. Problem Solving: Addressing any issues or questions that arise during the authorization process. f. Provide Education: Educate patients, providers, and staff on prior authorization processes, eligibility requirements, and appeal procedures. 6. Will be responsible to monitor and improve associated key performance indicators.
TEAM MEMBER OBJECTIVE: 1. Secure patients' demographics and medical information by using great discretion and ensuring that all procedures are in sync with HIPAA compliance and regulations 2. Operate online insurance verification websites. 3. Understand that the stress of illness may alter patient behavior and ability to follow through on plan of health care; interact with respect, including situations where patient and/or family display anger or distress. 4. Promote patient welfare and independence by communicating through words and actions and understanding of patients' reactions to the healthcare environment. 5. Relay information from the patient to the Provider. 6. Index documents in the patient's electronic record as needed. 7. Communicate the need for additional records that would support patient treatment to medical records or obtain them directly when accessible through IHDE. 8. Comply with patient satisfaction, customer service, and ambulatory care standards. Demonstrates respect for IGA policies for security, privacy, and confidentiality while using IGA equipment. Follows personnel policies within the IGA personnel manual 9. Maintain HIPAA compliance (patient privacy). Adhere to National Patient Safety goals. 10. Assist with quality improvement projects. 11. Demonstrate proficiency in use of the computer for all aspects of patient care and documentation including electronic medical records, other healthcare applications used, and Microsoft Office. 12. Assist with keeping the staff lounge neat. 13. Utilizes Microsoft Outlook email for all non-patient correspondence. 14. Immediately report any network, hardware, or software malfunction to the IT Officer or Supervisor. 15. Complete all required competencies and maintain skill level. 16. Recognize the need for continuous learning by attending staff development programs and workshops. 17. Serve on task forces/committees as requested. 18. Perform other duties as assigned.
REQUIRED SKILLS, KNOWLEDGE, AND ABILITIES Knowledge of medical terminology Knowledge of insurance guidelines and authorization requirements Strong Attention to detail, as accuracy is crucial for ensuring correct information is submitted and that authorizations are obtained appropriately Demonstrated customer-first attitude and philosophy Ability to learn computer and application skills as applicable to role Ability to interact with and work around people Ability to make judgments in demanding situations Ability to react to frequent changes in duties and volume of work Effective oral and written communication skills Ability to listen empathetically Ability to logically organize details Ability to manage multiple concurrent activities Knowledge of interpersonal communications in a complex organization Commitment to respectful patient and family-centered care Commitment to respectful treatment of all colleagues Commitment to patient privacy Commitment to patient safety QUALIFICATIONS:
Registered Nurse (RN) or Licensed Practical Nurse License: A current and valid RN/LPN license is required. Graduate of Medical Assistant Program Certified Medical Assistant preferred Maintains Basic Life Support certification
PHYSICAL REQUIREMENTS: • Full Range of body motion, including handling and lifting patients • Requires working under stressful conditions and requires standing and walking for extended periods of time. • Exposure to communicable diseases and/or bodily fluids • Ability to safely and successfully perform the essential job functions consistent with the ADA, FMLA and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards. • Ability to maintain regular, punctual attendance consistent with the ADA, FMLA, and other federal, state and local standards. • Must be able to lift and carry up to 50 lb.
POTENTIAL EXPOSURE TO BLOOD AND BODILY FLUID:
(Please check the appropriate category below)
Category 1 - Performs tasks which involve exposure to blood, body fluid, or tissue. X
Category 2 - Performs tasks which involve no exposure to blood, body fluid, or tissue, but may perform unplanned Category 1 tasks.
Category 3 - Performs tasks that involve NO exposure to blood, body fluid, or tissue