Pre-Access Authorization Specialist

All the benefits and perks you need for you and your family:

-          Career Development

-          Whole Person Wellbeing Resources

-          Tuition Reimbursement          

Our promise to you:

Joining AdventHealth is about being part of something bigger. It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule: Monday-Friday 8:00am - 5:00pm

Location: 15 John Maddox Parkway, Rome, GA

The role you'll contribute:

The Pre-Access Authorization Specialist, under general supervision, maintains performance standards appropriate to area by obtaining account benefits and/or verifying authorizations are in place for all chemotherapy regimens and treatments, and meeting standards established by leadership for all patient services. Meets or exceeds department audit accuracy and productivity standard goal. Uses utmost caution that obtained benefits, authorizations, and/or pre-certifications are accurate according to the actual test, and procedure or registration being performed. Adheres to AdventHealth Corporate Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:

Responsible for review of treatment orders and determines insurance benefits and authorization requirements. Ensures specified medical terms, diagnosis, medication codes and supporting clinical documentations are met. Utilization review to facilitate the sending of clinical information in support of the authorization to payor or third-party administrators, as assigned.

Reviews medical records in detail to confirm the treatment is supported by approved medical studies. Ensures patient orders are changed accordingly if biosimilar drug is preferred. Ensures that each treatment is coded, reviewed, and financially cleared based on the patient insurance requirements.

Verifies medical necessity in accordance with Centers for Medicare & Medicaid Services (CMS) standards by reviewing guidelines and communicates relevant coverage/eligibility information to the patient. Alerts physician offices to issues with verifying insurance. Responsible for communicating to service line partners of situations where medical necessity is not met to include review of journal articles, compendia and/or peer review to justify medical necessity approval.

Reviews clinical records when following up on authorization request directly with a payor. Escalates peer to peer (insurance company physician requests to speak to ordering physician) requests to physician offices and assists in scheduling peer to peer requests with the office and the payer to ensure an authorization decision is made prior to date of

service.

Obtains initial and subsequent pre-authorization for medical treatments, as well as research protocols, on all new and existing patients and notes approvals in the electronic medical record. Uploads treatment supporting documentation packet to the electronic medical record for Revenue Cycle billing and coding teams.

The expertise and experiences you'll need to succeed:

Mature judgement in dealing with patients, physicians, and insurance representatives

Intermediate knowledge of Microsoft programs and familiarity with database programs

Ability to operate general office machines such as computer, fax machine, printer, and scanner

Ability to effectively learn and perform multiple tasks, and organize work in a systematic and efficient fashion

Ability to communicate professionally and effectively, both verbally and written

Ability to adapt in ever changing healthcare environment

Ability to follow complex instructions and procedures, with a close attention to detail

Adheres to government guidelines such as CMS, EMTALA, and HIPAA and AdventHealth corporate policies

Exceptional customer service skills

Advanced understanding of insurance knowledge and benefits

Advanced understanding of hospital electronic medical report (EMR) system

Basic medical terminology

Ability to communicate in English

Familiarity with medical terminology and concepts

Working knowledge with third-party insurance administrators authorization and clinical care processes

  KNOWLEDGE AND EXPERIENCE PREFERRED:

Understanding of HIPAA privacy rules and ability to use discretion when discussing patient-related information that is confidential in nature as needed to perform duties

Intermediate medical terminology

Bilingual - English/Spanish

EDUCATION AND EXPERIENCE REQUIRED:

High School Grad or Equiv and 3 years experience

One (1) year experience in healthcare related business operations within

specialty pharmacy or insurance verification, payor reimbursement guidelines and/or authorization submission.

One year of direct Patient Access experience

One year of customer service experience

  EDUCATION AND EXPERIENCE PREFERRED:

Two years of direct Patient Access experience

Associate's degree

Medical Assistant

  LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:

None