Prior Authorization Representative

Work Shift

Day

Scheduled Weekly Hours

40

Summary

This position supports Mercy's philosophy of patient centered care by possessing a complete understanding of health insurance industry requirements for preauthorization to ensure medical necessity and appropriateness of delivery of health care resources provided to members as per their benefit package. Responsible for initiating an accurate and complete preauthorization, making required edits on pre-authorizations and initiating follow up as needed.

Job Description

Job Duties

• Performs pre-authorization duties requiring good knowledge of hospital programs and procedures. Will obtain authorizations for test, procedures and medications, review for medical necessity and if meets criteria.
• Review Request: Assess prior authorization request for various medical services, procedures, and medications to determine if they meet the necessary criteria for approval.
• Verify Insurance: Confirm patient insurance benefits and eligibility, ensuring that the proposed services are covered under their plan.
• Possesses a complete understanding of health insurance industry requirement for preauthorization per payer.
• Documentation: Prepare and submit detailed authorization requests to insurance   companies, including all required documentation to support the request. 
• Understands ICD-10 coding systems for local medical review policies (LMRP), national coverage determination (NCD) and pre-authorization process required.
• Record Keeping: Maintain accurate records of all prior authorization requests, documenting approvals, denials, and follow-up actions.
• Problem Solving: Investigate and resolve issues related to denied authorizations, including resubmitting requests and appealing decisions when necessary. 
• Monitor AI 278 EDI transactions to ensure Records are attached and approvals are received before services are rendered.
• Interacts with providers/clinical teams for any additional documentation needed.
• Appeals denials and communicate with clinical team on the status of the appeal and if a peer to peer need to be done.  Documents all information for the office to call on a peer to peer. 
• Communication: Act as a liaison between patients, healthcare providers, and insurance companies, effectively communicating the status of authorization requests and any necessary follow-up actions. 
• Initiates waivers when services are denied. Calls patient or guarantor to explain and gives cost of test/procedure and reason for denial.  
• Uses the call manager and computer to perform all pre-authorization and scheduling duties.
• Follows Mercy's safety guidelines, carries out job-specific safety duties and responsibilities, and promptly reports any unsafe conditions, situations, incidents and injuries.

Knowledge, Skills and Abilities

• Basic proficiency in operation of computer, basic keyboarding, fax machine, filing systems, and telephone systems or call center knowledge.
• Knowledge of medical terminology, anatomy strongly preferred.
• Knowledge of ICD-10 coding systems for local medical review policies (LMRP), national coverage determination (NCD) and pre-authorization process required.
• Excellent interpersonal and customer service skills.
• Excellent oral and written communication skills.
• Ability to perform multiple tasks with constant interruptions.

Professional Experience

• Proficiency in Medical Terminology and coding (CPT and ICD-10) is essential for accurately processing requests.  
• Previous experience in medical billing, healthcare administration, or a related field is typically required. 
• Communication Skills: Strong verbal and written communication skills are necessary for effective collaboration with healthcare providers and insurance representatives
• The ability to navigate complex situations and resolve issues for authorizations. 

Education

• High School Diploma or equivalent strongly preferred. Relevant experience to be considered in lieu of degree.
• Preferred: Associates degree, graduate of HIM program, RHIT or RHIA certification.

Licensure, Certification, Registration

• None required.

Physical Requirements

Sedentary: Exert up to 10 lbs. of force occasionally and/or a minute amount frequently

Pay Rate Type

Hourly

Mercy is an independent, community-based organization supporting the Cedar Rapids area for over 120 years.

Mercy is an equal-opportunity employer. We value diversity, equity, and inclusion and therefore evaluate qualified applicants without regard to race, color, ethnicity, ancestry, sex, sexual orientation, gender identity, marital status, civil union status, parental status, religion, national origin, age, disability, veteran status, and other legally protected characteristics.