ABOUT NCH
NCH is an independent, locally governed non-profit delivering premier comprehensive care. Our healthcare system is comprised of two hospitals, an alliance of 700+ physicians, and medical facilities in dozens of locations throughout Southwest Florida that offer nationally recognized, quality health care.
NCH is transforming into an Advanced Community Healthcare System(TM) and we’re proud to: Provide higher acuity care and Centers of Excellence; Offer Graduate Medical Education and fellowships; Have endowed chairs; Conduct research and participate in national clinical trials; and partner with other health market leaders, like Hospital for Special Surgery, Encompass, and ProScan.
Join our mission to help everyone live a longer, happier, healthier life. We are committed to care and believe there's always more at NCH - for you and every person we serve together. Visit nchjobs.org to learn more.
JOB SUMMARY
The Medication Prior Authorization Specialist is responsible for all aspects of the prior authorization process. Responsibilities include collecting all the necessary documentation, contacting the client/patient for additional information and completion of the required prior authorization. Complete, timely, and accurate identification and submission of prior authorization requests to the insurance company. Interacts with clients, insurance companies, patients, and med representatives, as necessary, to request for prior authorizations. Responsible for documenting account activity, updating patient and claim information and demonstrates proficiencies with Covermymeds system to ensure all functionalities are utilized for the most efficient processing of claims and identifies prior authorization trends and/or issues resulting in delayed claims processing. Provides the highest level of customer service to clients/patients.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Other duties may be assigned.
· Documenting patient charts and relaying information & instructions to patient/family. Document all interventions, phone calls, patient/family responses, medication dispensed or prescribed, hospital data, etc. in medical record.
· Answering patient phone calls & messages and acting as a communication liaison between the patient and provider.
· Fulfills clerical responsibilities as assigned which may include filing or sending medical records to a patient or referral provider, appointment scheduling.
· Utilizes electronic referrals process to complete requested physician referrals to NCHMD specialists and ancillary services.
· Performs daily activities of checking to ensure accurate claim information, obtaining needed medical information for each prior authorization, appeal, or tier exception request.
· Document eligibility, benefit, and authorization information in accordance with established guidelines.
· Research patient accounts due to invalid and/or missing authorization information due to incorrect insurance information in chart, and correspond with clients, insurance companies, patients, sales representatives to obtain the necessary information to ensure accurate, timely and complete claims submissions.
· Verify that the medication that is being requested is prescribed by the company you work for before proceeding with prior authorization.
· Proactively manages and maintains all outstanding prior authorizations, non-formulary exceptions, tier exceptions, and appeal requests.
· Provide outstanding customer service to patients and develop and maintain positive working relationships with insurance companies.
· Identify primary insurance over secondary insurance.
· Document all account activity and correspond to inquiries in a timely manner.
· Review prior authorization requests daily.
· Communicates and works effectively with colleagues from other departments.
· Follows written and verbal communications.
· Follows all health and safety policies and procedures.
· Performs other related duties as required or assigned.
EDUCATION, EXPERIENCE AND QUALIFICATIONS
· Minimum of High School or GED required.
· Completion of Medical Assistant or practical nursing training program with documented clinical practicum hours; OR Medical Assistant certification; OR a minimum of one-year experience in medical office setting as a Medical Assistant or like role.
· Minimum of 2 years of Medication verification/authorization experience.
· Current certification in Basic Life Support for Healthcare Providers from the American Heart Association or American Red Cross required.
· Excellent verbal and written communication skills with ability to effectively articulate and explain required information to patients.
· Knowledge of CPT and ICD9 codes.
· Knowledge of basic and specialty specific medical terminology.
· Capable of working under pressure in a fast-paced environment with frequent interruptions while maintaining a professional demeanor and control.
· Prior Authorization Certified Specialist (PACS) preferred.
· Intermediate computer knowledge: Uses Microsoft Word, Excel, Outlook, and Windows.