Description

Purpose:
To perform authorization activities of inpatient, outpatient, and emergency department patients, denial management, and all revenue functions. Need to demonstrate, through actions, a consistent performance standard of excellence to which all work is to conform. The expertise of the Authorization Specialist shall include working knowledge in authorization-related activities including pre-authorizations, notifications, edits, denials, etc. The Authorization Specialist shall demonstrate the philosophy and core values of UPMC in the performance of duties.

Responsibilities:

• Review and interpret medical record documentation for patient history, diagnosis, and previous treatment plans to pre-authorize insurance plan-determined procedures to avoid financial penalties to the patient, the provider, and the facility.
• Utilize payor-specific approved criteria or state laws and regulations to determine medical necessity or the clinical appropriateness for inpatient admissions, outpatient facility, office services, durable medical equipment, and drugs in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease.
• Ensure accurate coding of the diagnosis, procedure, and services being rendered using ICD-9-CM, CPT, and HCPCS Level II.
• Provide referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive nonclinical administrative time required of providers.
• Submit pertinent demographic and supporting clinical data to payor to request approval for services being rendered.
• Maintain compliance with departmental quality standards and productivity measures.
• Work collaboratively with internal and external contacts specifically, Physician Services and Hospital Division, across UPMC as well as payors to enhance customer satisfaction and process compliance, ensuring the seamless coordination of work and to avoid a negative financial impact.
• Utilize 18+ UPMC system and insurance payor or contracted provider web sites to perform prior authorization, edit, and denial services.
• Utilize authorization resources along with any other applicable reference material to obtain accurate prior authorization.
• Retrospective authorization responsibilities. Resolves basic authorization edits to ensure timely claim filing and elimination of payor rejections and or denials.

Qualifications

• High School diploma or equivalent with 2 years working experience in a medical environment (such as a hospital, doctor's office, or ambulatory clinic) OR an Associate's degree and 1 year of experience in a medical environment required. (Bachelor's degree (B.A) preferred)
• Completion of a medical terminology course (or equivalent) required
• Knowledge and interpretation of medical terminology, ICD-9, and CPT codes
• Must be proficient in Microsoft Office applications
• Excellent communication and interpersonal skills
• Ability to analyze data and use independent judgment
• Understanding of authorization processes, insurance guidelines, third party payors, and reimbursement practices
• Experience with utilizing a web-based computerized system.

Licensure, Certifications, and Clearances:

• UPMC is an Equal Opportunity Employer/Disability/Veteran
• Individuals hired into this role must comply with UPMC’s COVID vaccination requirements upon beginning employment with UPMC. Refer to the COVID-19 Vaccination Information section at the top of this page to learn more.

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Our Values

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