Prior Authorization Coordinator

Description

AIM OF THE POSITION  

The Prior Authorization Coordinator is responsible for requesting authorization for all applicable incoming orders. This process includes understanding of payers’ medical policies for our services, collecting and reviewing all the necessary documentation required to submit prior authorization, contacting the ordering physician or their office for additional information when applicable, completing the required authorization submission forms within allotted timeframes and, follow-up with the payor to obtain an authorization determination. When applicable, the Prior Authorization Coordinator will also submit a Prior Authorization appeal if criteria is met but the Prior Authorization was denied erroneously.

POSITION WITHIN THE ORGANIZATION

1. Customer Care, Sales, Commercial and external vendors

2. Cooperates with all departments across the organization

Requirements

ESSENTIAL DUTIES AND RESPONSIBILITIES  

• Reviews incoming assigned orders to determine if authorization is required

• Reviews documentation from ordering physician for completeness to meet the payor requirements.

• When needed, contacts ordering physician's office to obtain missing documentation.

• Communicate with physician offices and/or sales team for assistance with authorization submissions, when applicable

• Verifies the diagnosis code provided by the billers to ensure that it is in line with current ICD 10 requirements

• Completion of authorization through the proper avenue (i.e., Phone, Glidian, Payor Portal, Fax).

• Document the Salesforce Billing Detail screen with the proper statuses and actions including Criteria Reason when applicable.

• Upload all written authorization determinations either from the payor portal or received via Fax or US mail.

• Follow up on all open authorization submissions.

• Additional tasks as needed

The above listing represents the general duties considered essential functions of the job and is not to be considered a detailed description of all the work requirements that may be inherent in the position. 

KEY CONTACTS

• Internal: This position may interface with various departments within the company.

• External: Clients and Payors

EDUCATION AND EXPERIENCE REQUIREMENTS

EDUCATION

• High School diploma or general education degree

• 1 + years related experience preferable 

KNOWLEDGE, SKILLS AND ABILITIES (KSA’S) 

Specific Knowledge Required: 

Knowledge: Comprehension of a body of information acquired by experience or study. 

Skill: A present, observable competence to perform a learned activity. 

Ability: Competence to perform an observable behavior. 

• Medical Pre-Authorization knowledge/experience 1 + years

• Knowledge of CPT and ICD 10 codes

• Previous medical billing experience preferred

• Ability to read and understand medical payer policies as well as pathology reports

• Ability to work with sensitive and confidential information

· PRIVACY NOTICE:  To review the California privacy notice, click here:  https://agendia.com/privacy-policy/ 

· Employees must not be classified as an excluded individual who is prohibited from participation in any Federal health care program.

BEHAVIOURAL COMPETENCIES/DESIRED SKILLS

• Must be able to work in a fast-paced environment 

• Must have strong organizational skills and attention to detail 

• High degree of accuracy 

• Manage Multiple tasks independently 

• Excellent problem resolution 

• Excellent customer service skills 

• "Outside the Box" thinker 

• Other Skills necessary: Analytical thinking, thoroughness, good research skills, and strong verbal/written communication.

WORKING ENVIRONMENT

Establishes ADA (Americans with Disabilities Act) requirements

ENVIRONMENT/SAFETY/WORK CONDITIONS

• General office environment. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Maintains a clean, neat, and orderly work area.

• Adheres to Department Specific Safety Guidelines.

• Standing, sitting, walking, bending, reaching, manual manipulation, and lifting up to 15 pounds.

TRAVEL

No travel is required.

OTHER DUTIES

Other duties as required by management