Copy of Prior Authorization Coordinator I

Our take on this role

About this role

Obtain insurance authorizations for medications, laboratory testing, and diagnostic imaging. Work with Pharmacy and clinical staff to track authorization decisions and assist with appeals when necessary.

What could you bring from clinical work?

• Nurses: Your experience reviewing clinical records for medication indications and treatment rationale could help you assist with writing letters of medical necessity.

Full job description from WACBD - Washington Center for Bleeding Disorders

About the role

Reporting to the Medical Billing Manager, the Prior Authorization Coordinator I (PAC) is responsible for obtaining authorizations for medications, laboratory testing, and diagnostic imaging for the Institute. The PAC I is responsible for following up with Pharmacy and the appropriate clinical team members on the determination of authorizations; and works closely with Pharmacy and clinical staff to ensure authorizations are complete and accurate and assists with appealing authorizations when necessary.

Essential Responsibilities and Functions

• Obtains medication prior authorizations for patients filling prescriptions and coordinates with Pharmacy and clinical staff as needed to assist in achieving authorizations utilizing inter-department work queues
• Verifies insurance coverage and eligibility for patients
• Authorizes outpatient testing including laboratory studies and diagnostic imaging as requested by clinical staff utilizing inter-department work queues
• Completes and oversees the appeals of ordered medications, testing, and procedures, as necessary
• Assists with the writing of letters of medical necessity for insurance companies
• Maintains a current list of prior authorizations that are in process and their status
• Assists Pharmacy and clinical staff with tasks related to achieving prior authorizations
• Attends weekly Rounds meetings
• Ensures correct insurance registration setup in Nextgen for patients
• Connect patients to AR Specialist for insurance coverage issues
• Continuously identifies issues and trends impacting patient care, quality, timely reimbursement, and reports to leadership with potential solutions
• Attend collaborative meetings and organizational retreats
• Other duties as assigned

Qualifications

• Minimum of five years prior authorization experience
• Associate degree in a related field or equivalent combination of education and experience
• Knowledge of medical terminology utilized in medical billing, current office practices and procedures, and basic math
• Ability to work under minimal supervision with the ability to execute independent judgement and sound decision making
• Ability to read, interpret, and apply regulations, policies, and procedures
• Knowledge of or ability to learn procedure and disease codes utilized in medical billing; fiscal recordkeeping using an automated system and/or healthcare billing
• Knowledge of collection laws, regulations, and techniques
• Experience with Newleaf or related Pharmacy Billing software
• Experience with NextGen or related EMR/EHR software
• Ability to maintain confidentiality per HIPAA requirements
• Experience with Microsoft office/365
• Required physical activities while using a laptop include frequent sitting, talking, hearing, and repetitive motions of hands/wrists
• Required physical activities used less frequently include standing, walking, and reaching, kneeling, bending, and stooping

Professional Expectations

• Conduct oneself in a professional manner, exhibiting the highest regard for patients and fellow employees
• Understand role and responsibilities
• Comply with all organization policies and procedures
• Continuously seek professional development and keep abreast of hemophilia and bleeding disorder breakthroughs and news
• Cultivate diversity and respect