At UPMC, we are committed to keeping our communities safe and healthy as the COVID-19 pandemic unfolds. Visit upmc.com/vaccinesupport to learn more about how you can help.

Our recruiters will continue to fill positions throughout this time, but interviews and other processes may be modified to protect the safety of our candidates and employees. Thank you for your patience.

For more information about UPMC's response to COVID-19, please visit upmc.com/coronavirus.

Search Our Jobs

   Current UPMC employees must apply in HR Direct

Authorization Specialist

Description

UPMC Magee-Womens Hospital is seeking a Full-time Authorization Specialist!

This position will work 8:00 a.m. to 4:30 p.m. Hours are subject to change based on business needs.

The Authorization Specialist performs authorization activities of inpatient, outpatient, and emergency department patients, denial management, and all revenue functions. This employee needs 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 the area of authorization-related activities including pre-authorizations, notifications, edits, denials, etc. and they shall demonstrate the philosophy and core values of UPMC in the performance of duties.

Responsibilities:

  • Prior authorization responsibilities:
    • Reviews and interprets 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, provider, and facility.
    • Utilizes 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.
    • Ensures accurate coding of the diagnosis, procedure, and services being rendered using ICD-9-CM, CPT, and HCPCS Level II.
    • Provides referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive nonclinical administrative time required of providers.
    • Submits pertinent demographic and supporting clinical data to the payor to request approval for services being rendered.
  • General responsibilities:
    • Maintains compliance with departmental quality standards and productivity measures.
    • Works 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.
    • Utilizes 18+ UPMC system and insurance payor or contracted provider websites 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 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
  • Skills 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
  • Skills Preferred:
    • Understanding of authorization processes, insurance guidelines, 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. Minority/Females/Veterans/Individuals with Disabilities.

Total Rewards

More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life &emdash; 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.

   Current UPMC employees must apply in HR Direct