Prior Authorization Personnel - Fiscal
POSITION SUMMARY:This position conducts prospective review of authorization requests including selected specialties, medical treatments and services, hospital admissions, ancillary services, home care and out of area referrals making clinical decisions based on established criteria and regulatory requirements.
ESSENTIAL JOB DUTIES AND RESPONSIBLITIES
• Performs prior authorization and retrospective review according to MCG (Milliman Care Guidelines), Medicare Guidelines and established protocols to determine the medical appropriateness of request.
• Refers cases to Medical Director when the treatment request does not meet medical necessity guidelines or when a peer-to-peer conversation is necessary to establish appropriateness.
• Adheres to the Plan’s HIPAA and Privacy Standards and Confidentiality Agreement.
• Communicates with members of the treatment team, reviews medical records, uses clinical expertise and compares information to established guidelines and the member’s benefit plan.
• Identifies problems or complex cases and refers for possible case management intervention and identifies patients with chronic disease process for possible disease management intervention.
• Maintains a thorough understanding of the Plan’s provider contracts, authorization requirements and MCG criteria.
• Reviews authorization requests and communicates with the physicians’ offices when additional information is needed.
• Conveys and records authorizations clearly within the notes.
• Completes all necessary paperwork and approves or refers to PFS Director or Clinical Manager potential denials and documents in the computer system per established protocols.
• Develops, reviews and revises department policies to assure compliance with regulatory agencies.
• Participates in interdepartmental projects as needed.
• Attends meetings and in-service sessions, as directed.
• Maintains regular attendance and punctuality.
• Performs other duties as assigned
This position directly supervises business office and insurance billing staff positions.
Required Education and Experience
• Must have a valid current RN/LPN license with minimum of one year experience
• Must be CPR certified
• Must possess knowledge of ICD and CPT codes for the purpose of authorizations and knowledge of insurance plans and their rules.
Preferred Education and Experience
• Knowledge of filing records
• Knowledge of medical and nursing diagnosis
Additional Eligibility Qualifications
• The ability to maintain confidentiality is essential.
Position Type : Part Time
Shift : Day
Hourly Wage: $19.55 - $24.43 per/hour
373 E. Tenth Ave.
Springfield, Co 81073