Job Description

Job Title: Senior Authorization Specialist
Job ID: 746601
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility:
Department: Rev Cyc Care Mgmt
Location: 2 Hot Metal Street, Pittsburgh PA 15203

Description

UPMC Corporate Services is hiring a Senior Authorization Specialist to support the Revenue Cycle Care Management department during daylight hours, Monday through Friday.

In this role, you 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 will include an in-depth working knowledge in the area of authorization related activities including pre-authorizations, notifications, edits, denials, across service areas.

Responsibilities:
  • Attend Interagency Treatment Team Planning Meetings as deemed necessary
  • Choose appropriate test battery, conducts clinical interviews, administers and scores standardized psychological tests and prepares written report of evaluation.
  • Complete evaluations within forty-five days prior to the initiation or continuation of services and must be updated every six months
  • Conduct face-to-face, strength-based psychiatric or psychological evaluations and re-evaluations of children and adolescents. Evaluations will follow Guidelines For Best Practice in Child and Adolescent Mental Health Services' format
  • Demonstrate knowledge of behavior management techniques and skills to aid in the development of individualized behavior plans. Provide behavioral consultation to Specialty Counselors and/or other members of the treatment team
  • Demonstrates highly developed knowledge and skill in the area of differential diagnosis of psychiatric disorders.
  • Determine specific elements of medical necessity and rule-out the need for psychiatric hospitalization
  • Diagnosis must be listed in the most recent Diagnostic and Statistical Manual and include Axes I and II (or an ICD-9-CM diagnosis) and III-V
  • General responsibilities 1. 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.
  • Modify testing procedures as necessary to accommodate developmental sensory or cognitive status of patient.
  • Prior authorization responsibilities 1. 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.
  • Provide behavioral support as needed to specialty counselors, developmental specialists, and parents
  • Provide telephone, virtual or face-to-face feedback to patients and family's referral sources and other interested parties (schools) as requested.
  • Report progress assessments and evaluations to treatment team and enter into electronic record (PsychConsult)
  • Retrospective authorization responsibilities 1. 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.
  • Services prescribed must be consistent with Child and Adolescent Service System Program (CASSP) Principles: child-centered, family-focused, community-based, multi-system, culturally competent and least restrictive/least intrusive. Prescribed services should be individualized and based on the needs of the child/adolescent and family

Qualifications

  • High School diploma or equivalent with four years working experience in a medical environment (such as a hospital, doctors office, or ambulatory clinic) OR an Associates degree and two years of experience in a medical environment required. (Bachelors degree (B.A) preferred)
  • Completion of a medical terminology course (or equivalent) 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:
UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $16.23 to $25.77

Union Position: No

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