COVID-19 Vaccination Information

Across UPMC, our guiding principle is to always prioritize the safety of our employees, patients, and members. UPMC believes that vaccination is important, helps protect all, and advocates that everyone who can be vaccinated should be vaccinated.

UPMC complies with all governmental requirements related to local, state, and federal COVID-19 vaccination for employment. The Jan. 13 Supreme Court of the United States decision that the Centers for Medicare & Medicaid Services federal COVID-19 vaccine mandate will move forward requires UPMC to ensure employees either get vaccinated or receive a requested medical or religious exemption.

If you are not yet vaccinated, we urge you to get a vaccine now. You can schedule your COVID-19 vaccination through UPMC or visit a non-UPMC provider or UPMC Urgent Care location.

Proof of vaccination is not required upon hire; however, employees will be responsible for ensuring post-hire compliance by getting vaccinated or requesting a medical or religious exemption.

For more information about UPMC’s response to COVID-19, please visit UPMC.com/coronavirus.

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Sr. Authorization Specialist - Care Management | Western Psychiatric Hospital

Description

Purpose:
The Senior Authorization Specialist will perform authorization activities for a broader scope of inpatient, outpatient and emergency department patients, denial management and all revenue functions. They will need to demonstrate, through actions, a consistent performance standard of excellence to which all work is to conform. The expertise of the Senior Authorization Specialist shall include an in-depth working knowledge in the area of authorization related activities including pre-authorizations, notifications, edits, denials, across service areas or business units. The Senior Authorization Specialist shall demonstrate the philosophy and core values of UPMC in the performance of duties.

Responsibilities:

  • Maintains compliance with departmental quality standards and productivity measures.
  • Works collaboratively with internal and external contacts to enhance customer satisfaction and process compliance, to avoid a negative financial impact.
  • Utilizes 18+ UPMC applications and payor/ contracted provider web sites to perform prior authorization, edit, and denial services.
  • Provides on the job training for the Authorization Specialist.
  • Utilize authorization resources along with any other applicable reference material to obtain accurate prior authorization.
  • Reviews and interprets 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.
  • Utilizes 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.
  • Obtains 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.
  • Submits pertinent demographic and supporting clinical data to payor to request approval for services being rendered.
  • Provides referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive administrative time required of providers.
  • Reviews insurance payments and remittance advice documents for proper processing and payment of authorization claims, as appropriate.
  • Audits 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 prepares appeals for underpaid, unjustly recoded, or denied claims.
  • Submits requests for account adjustments/controllable losses to manager in accordance with departmental process.
  • Identifies authorization related edit/denial trends and causative factors, collates data, and provides summary of observations. Communicates identified trends to Manager.

Qualifications

  • 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.
  • Behavioral Health background is preferred.
  • EPIC knowledge is preferred.  
  • 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.
  • Understanding of authorization processes, insurance regulations, third party payors, and reimbursement practices
  • Experience utilizing a web-based computerized system

Licensure, Certifications, and Clearances:

  • Act 34 with renewal

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct

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