The Prior Authorization Specialist will obtain prior authorizations for diagnostic imaging, cardiac imaging, medications including hospital administered IV infusions, Veterans Administration authorizations, and referral authorizations for some specialist appointments. This position will secure the prior authorization and notify the rendering party in the timeliest manner possible so our patient receives the services needed with the least delay.

Principal Duties and Responsibilities (*Essential Functions)

1. Receive request for prior authorizations and ensure that they are properly and closely monitored.
2. Process referrals and submit medical records to insurance carriers to expedite prior authorization processes.
3. Manage correspondence with insurance companies, physicians, specialist and patients as needed, including documenting in the EHR as appropriate.
4. Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed.
5. Review accuracy and completeness of information requested and ensure that all supporting documents are present.
6. Review denials and follow up with provider to obtain medically necessary information to submit an appeal of the denial.
7. Prioritize the incoming authorizations by level of urgency to the patient.
8. Secure patient information in accordance with The Methodist Hospitals policy/procedures.
9. Other duties as assigned.

Job Specific (Minimum Requirementes)

Knowledge, Skills, and Abilities

Knowledge of insurance process and medical terminology

Education

HS Diploma/GED Equivalent in General Studies is Required.

Experience

2 Years of experience in Prior Authorization Physician office based or hospitals based is Preferred.

Certifications and Licensures

Certified Professional Coder (CPC) is Preferred.

Model of Care and Conduct

Methodist Hospitals strives for excellence and insists on high standards of conduct and performance in everything we do. Our Model of Care and Conduct is designed to create a positive work environment which Methodist desires for all employees. This is foundational to the high level of patient, family and physician satisfaction we strive for each day. As part of all position’s duties at Methodist Hospitals, all employees are responsible to conduct themselves in accordance with the Model of Care and Conduct and will be evaluated according to these

Standards of Behavior.