Description

University of Pittsburgh Physicians is hiring a Senior Authorization Specialist to join their Women's Health team at Magee Women's Hospital! This position will work Monday through Friday, 7:30am to 4:00pm with no weekends or holidays! This position will offer some work from home flexibility after completion of an orientation period.

This position will work with The Center for Fertility and Reproductive Endocrinology, which offers a woman-focused approach, knowledge, and expertise to provide highly personalized reproductive health care, including evaluation, diagnosis, and treatment. The Center provides the most recent advances in virtually all aspects of reproductive healthcare. The Center is designed to address all aspects of women's reproductive healthcare and includes psychosocial as well as medical and surgical services.

This position will perform authorization activities for a broader scope of inpatient, outpatient and emergency department patients, denial management and all revenue functions. The expertise of the Authorization Specialist Senior 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. 

Responsibilities:

• General responsibilities1. Maintains compliance with departmental quality standards and productivity measures. 2. Works collaboratively with internal and external contacts to enhance customer satisfaction and process compliance, to avoid a negative financial impact.3. Utilizes 18+ UPMC applications and payor/ contracted provider web sites to perform prior authorization, edit, and denial services.4. Provides on the job training for the Authorization Specialist.5. Utilize authorization resources along with any other applicable reference material to obtain accurate prior authorization.
• Prior authorization responsibilities1. 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. 2. 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. 3. 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. 4. Submits pertinent demographic and supporting clinical data to payor to request approval for services being rendered. 5. Provides referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive administrative time required of providers.
• Retrospective authorization responsibilities1. Reviews insurance payments and remittance advice documents for proper processing and payment of authorization claims, as appropriate. 2. Audits authorization related data errors and/or completes retro-authorizations to resolve unprocessed or denied claims. 3. Researches denials by interpreting the explanation of benefits or remittance codes and prepares appeals for underpaid, unjustly recoded, or denied claims. 4. Submits requests for account adjustments/controllable losses to manager in accordance with departmental process. 5. 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

Skills Required: 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

Skills Preferred: 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


• UPMC is an Equal Opportunity Employer/Disability/Veteran

UPMC has a Center for Engagement and Inclusions that is charged with executing leading-edge and next- generation diversity strategies to advance the organization’s diversity management capability and its national presence as a diversity leader.  This includes having Employee Resources Groups, such as PRIDE Health or UPMC ENABLED (Empowering Abilities and Leveraging Difference) Network, that support the implementation of our diversity strategy.

Total Rewards

More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life — because we believe that you’re at your best when receiving the support you need: professional, personal, financial, and more.

Our Values

At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.