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Trinity Health - IHA Prior Authorization Specialist-Call Ctr Medication-High Tech Imaging in Ann Arbor, Michigan

POSITION DESCRIPTION:

Responsible for reviewing, submitting, monitoring and responding to issues regarding prior authorization for either high tech radiology services (MRI, CT, PET Scans, etc.), medications, or procedures for IHA patients. Reviews patient medical history to identify supporting documentation in the patient chart relevant to the medication, service or procedure; contacts insurance companies and obtains authorization.

ESSENTIAL JOB FUNCTIONS:

  • Responsible for reviewing, submitting, monitoring and responding to issues regarding prior authorizations for high tech radiology services, medications, or procedures for IHA patients.

  • Professionally communicates with the ordering provider, practice support staff and representatives of insurance companies, including oral and written communication.

  • Reviews patient medical history to identify supporting documentation in the patient chart relevant to the medication or procedure.

  • Contacts insurance companies or appropriate third party and obtains authorization.

  • Updates information in patient medical record (EMR) with approval or declination information; follows up with Primary Care Physician as to status and/or issues with prior authorizations.

  • Monitors task box, email and fax server if applicable. Follows up on correspondence timely and accurately.

  • Obtains urgent authorizations same day, next day.

  • Verify correct procedural codes, diagnostic codes and insurance verification.

  • Participates in data collection and data review assignments as required.

  • Monitor authorizations or denials and follows up as necessary.

  • Performs other duties and participates in special projects as assigned.

ORGANIZATIONAL EXPECTATIONS:

  • Creates a positive, professional, service-oriented work environment for staff, patients and family members by supporting the IHA CARES mission and core values statement

  • Must be able to work effectively as a member of the Call Center team.

  • Successfully completes IHA's "The Customer" training and adheres to IHA's standard of promptly providing a high level of service and respect to internal or external customers.

  • Maintains knowledge of and complies with IHA standards, policies and procedures, including IHA's Employee Handbook.

  • Maintains complete knowledge of office services and in the use of all relevant office equipment, computer, and manual systems

  • Maintains strict patient and employee confidentiality in compliance with IHA and HIPAA guidelines

  • Serves as a role model, by demonstrating exceptional ability and willingness to take on new and additional responsibilities. Embraces new ideas and respects cultural differences.

  • Uses resources efficiently.

  • If applicable, responsible for ongoing professional development – maintains appropriate licensure and continuing education credentials, participates in available learning opportunities.

MEASURED BY:

Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position.

ESSENTIAL QUALIFICATIONS:

EDUCATION: Undergraduate degree or Associate's degree in healthcare or related field and specialized training or equivalent combination of education and experience.

CREDENTIALS/LICENSURE: None

MINIMUM EXPERIENCE: 4 years' experience with insurance referrals, prior authorization or other relevant medical office experience.

POSITION REQUIREMENTS (ABILITIES & SKILLS):

  • Proficient/knowledgeable in medical terminology.

  • Proficient knowledge of major health plans and insurance processes.

  • Proficiency in operating a standard desktop and Windows-based computer system, including but not limited to, electronic medical records, email, e-learning, intranet and computer navigation. Ability to use other software as required while performing the essential functions of the job.

  • Excellent communication skills in both written and verbal forms, including proper phone etiquette.

  • Ability to work collaboratively in a team-oriented environment; courteous and friendly demeanor.

  • Ability to work effectively with various levels of organizational members and diverse populations including IHA staff, providers, patients, vendors, family members, outside customers and community groups.

  • Ability to cross-train in other areas of practice in order to achieve smooth flow of all operations.

  • Good organizational and time management skills to effectively juggle multiple priorities, time constraints and ever-changing medical situations.

  • Ability to exercise sound judgement and problem-solving skills.

  • Ability to perform mathematical calculations needed during the course of performing basic job duties.

  • Knowledge of the compliance aspects of clinical care and patient privacy and best practices in medical office operations.

  • Ability to handle patient and organizational information in a confidential manner.

  • Successful completion of IHA competency-based program within introductory and training period.

MINIMUM PHYSICAL EXPECTATIONS:

  • Physical activity that often requires keyboarding, phone work and charting.

  • Physical activity that often requires time working on a computer.

  • Physical activity that sometimes requires walking, standing, bending, stooping, reaching, an/or twisting.

  • Physical activity that sometimes requires lifting, pushing and/or pulling up to 20 lbs.

  • Specific vision abilities required include close vision, depth perception, color vision, peripheral vision and the ability to adjust and focus.

  • Manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment.

  • Must hear and speak well enough to conduct business over the telephone or face to face for long periods of time in English.

MINIMUM ENVIRONMENTAL EXPECTATIONS:

This job operates in a typical office environment which involves frequent interruptions and significant interaction with people (some of whom are scared, hurt and/or ill) which can be stressful and result in competing priorities.

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