Senior Authorization Specialist

General Responsibilities

• Maintain compliance with departmental quality standards and productivity measures.
• Work collaboratively with internal and external contacts to enhance customer satisfaction and process compliance, to avoid a negative financial impact.
• Utilize 18+ UPMC applications and payor/ contracted provider web sites to perform prior authorization, edit, and denial services.
• Provide on the job training for the Authorization Specialist.
• Utilize authorization resources along with any other applicable reference material to obtain accurate prior authorization.

Prior Authorization Responsibilities

• Review and interpret pertinent medical record documentation for patient history, diagnosis, and previous treatment plans to pre-authorize insurance plan determined procedures to avoid financial penalties to patient, provider and facility.
• Utilize payor-specific criteria or state laws and regulations to determine medical necessity for the clinical appropriateness for a broad scope of services and procedures considered effective for the patient's illness, injury, or disease.
• Obtain appropriate diagnosis, procedure, and additional service codes to support medical necessity of services being rendered using pertinent medical record and ICD-CM, CPT, and HCPCS Level II resources.
• Submit pertinent demographic and supporting clinical data to payor to request approval for services being rendered.
• Provide referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive administrative time required of providers.

Retrospective Authorization Responsibilities

• Review insurance payments and remittance advice documents for proper processing and payment of authorization claims, as appropriate.
• Audit authorization related data errors and/or completes retro-authorizations to resolve unprocessed or denied claims.
• Research denials by interpreting the explanation of benefits or remittance codes and prepare appeals for underpaid, unjustly recoded, or denied claims.
• Submit requests for account adjustments/controllable losses to manager in accordance with departmental process.
• Identify authorization related edit/denial trends and causative factors, collates data, and provides summary of observations. Communicate identified trends to Manager.
• High School diploma or equivalent with 4 years working experience in a medical environment (such as a hospital, doctor's office, or ambulatory clinic) OR an Associate's degree and 2 years of experience in a medical environment required. (Bachelor's degree (B.A) preferred)
• Completion of a medical terminology course (or equivalent) or has 3 years of experience working with medical field required.
• Skills Required: Knowledge and interpretation of medical terminology, ICD, and CPT codes; Proficient in Microsoft Office applications; Excellent communication and interpersonal skills; Ability to analyze data and use independent judgment
• Skills Preferred: Understanding of authorization processes, insurance regulations, third party payors, and reimbursement practices; Experience utilizing a web-based computerized system

Licensure, Certifications, and Clearances