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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