Job Description

Job Title: Pre-Authorization Specialist I
Department: Patient Access (pre-visit)
Shift: 1st
Specialty: Patient Access
Job Number: 2023-1655
Date Posted: 05/11/2023
Position Type: Administrative/Clerical

Job Qualifications:

Rush University Medical Center

Pre-Authorization Specialist I

Work Hours: 8:00am- 5:30pm

Position Highlights:
The Prior Authorization Specialist I is responsible for obtaining and resolving referral, precertification, and/or prior authorization to support insurance specific plan requirements for all commercial, government and other payors across hospital (inpatient & outpatient), ED, ancillary and clinic/ambulatory environments. In addition, the Prior Authorization Specialist I may be responsible for pre-appointment registration and insurance review to maximize the submission of a clean claim. Exemplifies the Rush mission, vision and values and acts in accordance with Rush policies and procedures.

Position Responsibilities:
Reviews, collects and properly records demographic and insurance information required to properly address the customers' authorization requirements and identify any financial issues. Verifies patient's eligibility from resources provided by third party payers and portals and other on lines services.
Collects and analyzes demographic, insurance and other information from the patient, guarantor and all other sources to accurately obtain authorization for scheduled procedure.
Assembles information concerning the patient's clinical background and clinical information that is required for the payer to issue a referral or an authorization. Per referral guidelines, provide appropriate clinical information to the payer.
Contact review organizations and insurance companies to ensure prior approval requirements are met. Present necessary medical information such as history, diagnosis, CPT codes and clinical notes. Provide specific medical information to financial services to maximize reimbursement to the hospital and professional service providers.
Performs registration functions consistent with Federal, State and Local regulatory agencies and payer requirements, and organizational policies and procedures, including HIPAA privacy and security Regulations, as well as JACHO.
Consistently maintains authorization accuracy rates at and or above department standard in performance of registration and authorization duties.
Customers. Able to find resolution within the phone interaction satisfactory to the caller and/or having the knowledge when to escalate to their supervisor.
Interacts and collaborates with numerous departments to resolve issues while also analyzing necessary information that will ensure hospital reimbursement.
Appropriately informs the patients of hospital policies that govern the revenue cycle, the amount owed by the patients and explains hospital payment policy. Offers option of Financial Counselors to assist in acceptable resolution of estimated patient balance.
Receives and properly responds to, or directs telephone and electronic inquiries from patients, payers, physicians and their staff, internal department and other persons and entities. Ability to exercise good customer service skills when communicating with both our patients as well as our internal customers. Able to find resolution within the phone interaction satisfactory to the caller and/or having the knowledge when to escalate to their supervisor.
Performs other duties as assigned for the operational effectiveness and success of the department.
Interacts and collaborates with numerous departments to resolve issues while also analyzing necessary information that will ensure hospital reimbursement.
Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Rush University Medical Center's Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical, and professional behavior. Guards to assure that HIPAA confidential medical information is protected
Attends regular EPIC training sessions or other sessions conducted for the benefit of associates involved in the Financial Counseling functions.
Other duties as needed and assigned by the supervisor/manager.

Required Job Qualifications:

High school graduate or equivalent.
year of experience
Must have a basic understanding of the core Microsoft suite offerings (Word, PowerPoint, Excel).
Excellent communication and outstanding customer service and listing skills.
Basic keyboarding skills
Ability to analyze and interpret data
Critical thinking, sound judgment and strong problem-solving skills essential
Team oriented, open minded, flexible, and willing to learn
Strong attention to detail and accuracy required
Ability to prioritize and function effectively, efficiently, and accurately in a multi-tasking complex, fast paced and challenging department.
Ability to follow oral and written instructions and established procedures
Ability to function independently and manage own time and work tasks
Ability to maintain accuracy and consistency
Ability to maintain confidentiality

Preferred Job Qualification:
Associates Degree in Accounting or Business Administration
Experience within a hospital or clinic environment, a health insurance company, managed care organization or other health care financial service setting, performing medical claims processing, financial counseling, financial clearance, accounting, or customer service.
Knowledge of insurance and governmental programs, regulations, and billing processes e.g., Medicare, Medicaid, Social Security Disability, Champus, Supplemental Security Income Disability, etc., managed care contracts and coordination of benefits is highly desired.
Working knowledge of medical terminology and anatomy and physiology is preferable.



Company Highlights:
Ranked among the top academic medical centers in the country, Rush University Medical Center is an outstanding place to enhance your career. Everything we do centers on one goal: improving patient care.
Leading academic medical center, acute care hospital w/ 664 licensed beds.
Ranked among the top 20 "Best Places to Work" by Indeed.
In U.S. News & World Report's 2017-2018 Best Hospitals issue, Rush ranked among the top 50 hospitals in 8 of 16 categories.
Rush University Medical Center received five stars in a quality rating system by the federal Centers for Medicare and Medicaid Services (CMS). Rush University Medical Center is the only five-star academic medical center in the Chicago area.
Rush has been named one of the 100 Top Hospitals in the country by Truven Health Analytics three times.
Rush is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics.

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