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Authorization Specialist

  • Job ID: 803042915
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: University of Pittsburgh Physicians
  • Department: 65864 POP18 PEDS Rheumatology
  • Location: 4401 Penn Avenue, Pittsburgh PA 15224
  • Union Position: No
  • Salary Range: $16.37 to $25.78 / hour

Description

Purpose:

UPMC Children's Hospital of Pittsburgh is hiring Authorization Specialist for Division of Pediatric Division of Rheumatology.  they will 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 the area of 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:

 

  • Prior authorization responsibilities1. 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 patient, provider and facility. 2. 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. 3. Ensures accurate coding of the diagnosis, procedure, and services being rendered using ICD-9-CM, CPT, and HCPCS Level II. 4. Provides referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive nonclinical administrative time required of providers. 5. Submits pertinent demographic and supporting clinical data to payor to request approval for services being rendered.
  • General responsibilities:1. Maintains compliance with departmental quality standards and productivity measures. 2. 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.3. Utilizes 18+ UPMC system and insurance payor or contracted provider web sites to perform prior authorization, edit, and denial services.4. Utilize authorization resources along with any other applicable reference material to obtain accurate prior authorization.
  • Retrospective authorization responsibilities1. Resolves basic authorization edits to ensure timely claim filing and elimination of payor rejections and or denials.
  • Schedules, reschedules patient appointments.
  • Works with physicians to ensure patient billing is submitted in a timely manner.
  • Prepares patient medical records for scanning by HIM personnel.
  • Gathers medical records related to patient visit for physician's review.
  • Reviews physicians' schedules to ensure adequate appointments are available. Reports issues to manager in a timely manner. Makes changes to schedules as directed by manager or physicians.
  • Arranges infusions and procedures for patients. Obtains referrals/authorizations from insurance companies when indicated and documents in appropriate computer systems.

 

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
  • 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
  • Skills Required: Knowledge and interpretation of medical terminology, ICD-9, 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 guidelines, third party payors, and reimbursement practices. Experience utilizing a web-based computerized system.


Licensure, Certifications, and Clearances:

UPMC has a Center for Engagement and Inclusion 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 Resource Groups, such as PRIDE Health or UPMC ENABLED (Empowering Abilities and Leveraging Differences) Network, that support the implementation of our diversity strategy. 

  • Act 31 Child Abuse Reporting with renewal
  • Act 33 with renewal
  • Act 34 with renewal
  • Act 73 FBI Clearance with renewal

  • UPMC is an Equal Opportunity Employer/Disability/Veteran

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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