Description

Purpose:
The Sr Authorization Specialist will perform authorization activities for a broader scope of inpatient, outpatient and emergency department patients – (this will be only outpatient authorizations), denial management and all revenue functions. The employee will need to demonstrate, through actions, a consistent performance standard of excellence to which all work is to conform. 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. The Authorization Specialist Senior 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.-( we only have one authorization specialist in the department so there will be no training involved.
• 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.
• 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.
• Retrospective authorization responsibilities: 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.
• Researches 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.
• 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 31 Child Abuse Reporting
• Act 33
• Act 34
• Act 73 FBI Clearance

UPMC is an Equal Opportunity Employer/Disability/Veteran

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