A Insurance Pre-Authorization Specialist reviews all DMH and Memorial Care scheduled inpatient and outpatient procedures and outpatient diagnostic services to validate the scheduled procedure or diagnostic service has the appropriate payor authorization or meets the payor’s medical policies, there is a valid physician order, and other clinical documentation requirements are met prior to the scheduled procedure or diagnostic service. Coordinates physician referrals on patient accounts deemed appropriate  for additional services. Schedules, coordinates and pre-authorizes needed services ordered by the physicians. 

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required. 

• Must possess good communication and interpersonal relationship skills.
• Must be able to organize work with minimal supervision.
• Must be able to focus attention to minute details.
• Above average computer skills including Word, Excel and software applications required.

General Skill Requirements

In addition to the Essential Functions and Qualifications listed above, to perform the job successfully an individual must also possess the following General Skill Requirements.

• Adaptability – Adapts to changes in the work environment; Manages competing demands; Accepts criticism and feedback; Changes approach or method to best fit the situation; ability to work with frustrating situations; work under pressure and on an irregular schedule such as unscheduled overtime, unanticipated changes in work pace; Works with numerous distractions.
• Attendance and Punctuality – Schedules time off in advance; Begins working on time; Keeps absences within guidelines; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time.
• Communications – Expresses ideas and thoughts verbally; expresses ideas and thoughts in written form; Exhibits good listening and comprehension; Keeps others adequately informed; Selects and uses appropriate communication methods.
• Cooperation – Establishes and maintains effective relations; Exhibits tact and consideration; Displays positive outlook and pleasant manner; Offers assistance and support to co-workers; Works cooperatively in group situations; Works actively to resolve conflicts.
• Job Knowledge – Competent in required job skills and knowledge; Exhibits ability to learn and apply new skills; Keeps abreast of current developments; Requires minimal supervision; Displays understanding of how job relates to others; Uses resources effectively.
• Judgment – displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions; ability to work with and maintain confidential information.
• Problem solving – Identifies problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Resolves problems in early stages; Works well in group problem solving situations.
• Quality – Demonstrates accuracy and thoroughness; Displays commitment to excellence; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.
• Quantity – Meets productivity standards; Completes work in timely manner; Strives to increase productivity; Works quickly; Achieves established goals.
• Concentration – Maintains attention to detail over extended period of time; continually aware of variations in changing situations.
• Supervision – ability to perform work independently or with minimal supervision; ability to assign and/or review work; train and/or evaluate other employees.

Education and/or Other Requirements

• Previous experience in customer service
• High school education or GED.
• Knowledge of medical service coding preferred
• Familiarity with medical terminology or willingness to learn.

Environmental Factors

This position is performed within an environment of minimal exposure to irritating, unpleasant, or hazardous elements or conditions.

Physical Demands

The physical demands described are representative of those that must be met by an employee to successfully perform the essential functions of this job.

• While performing the duties of this job, the employee is regularly required to sit and move through an office environment.

Mental Demands

• While performing the duties of this job, the employee must be able to work under stress, adapt to changing conditions, and meet strict time guidelines.

• Ability to adhere to strict confidentiality requirements.

• Understands and applies payor prior-authorization requirements, and stays current with payor changes.
• Interacts effectively with physicians and/or office staff when receiving information regarding hospital outpatient diagnostic services and referrals services needed.
• Provides information and assistance for Utilization Review and Patient Financial Services.
• Primary function is to receive and coordinate pre-authorizations/RQI’s on patient accounts for all outpatient services and schedule inpatient admissions.
• Coordinates physician referrals on patient accounts deemed appropriate for additional services. Schedules, coordinates and pre-authorizes needed services ordered by the physicians.
  • Coordinates phone calls in a positive and professional manner to meet departmental goals.
  • Prioritizes scheduled patients in accordance with managed care pre-auth requirements and medical necessity requirements.
  • Utilizes the account note function to record all telephone conversations, consultations, pertinent case specific information, and rationale for decision on cases, all reference numbers and authorization information.
  • Provides excellent customer service by adhering to quality standards and case management/confidentiality policy and procedures.
  • Communicates daily with appropriate parties for prior approval on patient accounts (case management or nurses at doctor’s offices).
  • Maintains/documents accurate record of insurance/pre-auth company information.
• Communicates barriers or process improvement opportunities to management.
• Assists in training new personnel or in implementing new procedures.
• Performs other duties as assigned.