Prior Authorization Coordinator

 Title :Prior Authorization Coordinator

Department :Medical

GENERAL RESPONSIBILITIES 

The Prior Authorization Specialist obtains insurance authorizations for medications, procedures, imaging, and external medical facility

visits as required by insurers/payors/providers within established timeframes.  To ensure a high-quality patient experience s/he will be

responsible for accurately completing all documents/forms used in the process in a timely manner. The Prior Authorization Specialist is

responsible for maintaining and managing resources required in processing authorizations and will provide updates to providers and

patients as needed. 

QUALIFICATIONS 

• High School graduate/diploma. 

• Post-secondary training in Medical Assistant Program/Professional School preferred 

• Bi-lingual desirable 

• Organizational skills 

• Computer literate  

• Excellent telephone/customer service skills 

• 1-year experience working with prior authorizations/referrals preferred 

• Ability to work independently and with a team 

PRIMARY CONTACTS 

External: Insurers/payors, patients, providers, pharmacy staff, hospital/labs, radiology offices, specialist offices 

Internal:  Providers, other department staff 

PHYSICAL EFFORT/ENVIRONMENT 

Frequent access to patients’ medical records. Confidentiality must be maintained in an open office environment to maintain patient and staff privacy. Organizational skills; phone, fax, copier, scanner, computer, writing, and typing. Moderate physical activity, walking, standing, stooping, and occasional lifting.   

JOB TYPE 

Full-time 

SIGNIFICANT JOB FUNCTIONS 

• Monitor all prior authorization queues; documents, telephone encounters, and labs  
• Obtains clinical documents in support of DI requests and submits requests to the health plan. 
• Outreaches to payor clinical nurse team as needed to facilitate PA process 
• Works with clinical care team to expedite urgent prior authorizations  
• Monitor’s queues for authorization approval letters then faxes or calls rendering facility, pharmacy and/or patient with approval information  
• Responds by the end of the business day to patient inquiries  
• Review faxes for pharmacy denials; then checks plan formulary or pharmacy recommendations for alternative medications covered by the plan and relays that information to the provider for approval and/or denial of the alternative 
• Review patient charts, progress notes, and medical history for tried and failed medications 

• Inform provider/prescriber of denials to determine if an appeal should be submitted and submit appeal if determined appropriate with all accompanying documentation when required 
• Maintains and updates insurer/payer contact information needed to complete the prior authorization process 
• Prepares responses to authorization denials within an appropriate timeframe. 
• Researches and works with the Practice Director/Manager to correct patient demographic errors 
• Re-routes documents/telephone encounters inappropriately sent to the prior authorization queue 
• Contact patients to request/confirm preferred facility for DI if not previously determined 
• Contact patient to verify list of failed medications if not listed in provider note 
• Fax clinical notes to insurer when prior authorizations are initiated for patients from another facility 
• Scan approval letters faxed to administration office fax/fax/another fax machine and not to the primary fax machine 
• Contact insurer to check on status of outstanding prior authorization requests 
• Monitor eCW to verify fax confirmations; resend failed faxes 
• Research provider information (NPI, address, phone/fax) and CPT codes for out of network or medical prior authorization requests 
• For patients with Medicare Part D, contact plan or pharmacy to verify the correct plan and ID number 
• Act as a liaison with pharmacies, insurers, and rendering facilities as it relates to the prior authorization process 
• Proactively reach out to rendering facility scheduling departments to determine if patients scheduled for imaging require prior authorization  
• Update clinical team/providers regarding changes in requirements for prior authorization (sleep study documentation, etc.) 
• Closes prior authorization duplicates and TEs/documents once process is complete  
• Pro-actively reaches out to providers for clarification when needed 
• Follows standardized workflow to enable continuity and cross coverage between sites 
• Will assist Referral Coordinators (RC) with Pending Referrals/other as asked by manager and or when Prior Authoriz