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Authorization Specialist

  • Job ID: 036917511
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours: 8 a.m. to 4:30 p.m.
  • Shift: Day Job
  • Facility: UPMC Community Medicine Incorporated
  • Department: 55135 ZCMS1 Burke and Bradley Ortho
  • Location: 200 Delafield Rd, Pittsburgh PA 15215
  • Union Position: No
  • Salary Range: $15.24 to $23.27 / hour

Description

UPMC Community Medicine Incorporated is seeking a full-time Authorization Specialist to support Burke and Bradley Orthopedics at the UPMC St. Margaret Medical Arts Building!

Burke and Bradley Orthopedics is a busy, fast-paced, and renowned practice that focuses, specializes, and innovates in comprehensive sports medicine care.

The Authorization Specialist will support the practice by performing authorization activities for inpatient, outpatient, and emergency department patients. Responsibilities also include, but are not limited to, obtaining authorizations for MRIs and surgeries, handling denial management, executing revenue functions, communicating and coordinating with insurance companies, serving as back-up for charge entry, and working as a liaison between physicians, insurance companies, and patients.

The ideal candidate for this position will have a working knowledge of pre-authorizations, notifications, claims, edits, denials, and other authorization-related activities. Experience with CPT and ICD-10 coding is preferred, as are proficient computer and communication skills. The ability to work independently and meet deadlines is vital to this role, as is the ability to remain detail-oriented and focused. Any experience with orthopedics is a plus!

Burke and Bradley Orthopedics is committed to a standard of excellence for patient care, as well as to demonstrating the philosophy and core values of UPMC. If you are seeking a rewarding, exciting, and fast-paced environment, we invite you to apply today!


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-10-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 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, the Hospital Division, and payors) across UPMC to enhance customer satisfaction and process compliance, ensuring the seamless coordination of work and avoiding a negative financial impact.
    • Utilizes 18+ UPMC system and insurance payor or contracted provider websites to perform prior authorization, edit, and denial services.
    • Utilizes authorization resources along with any other applicable reference material to obtain accurate prior authorization.
    • Resolves basic authorization edits to ensure timely claim filing and elimination of payor rejections and or denials.

 

Qualifications

  • High School diploma or equivalent AND two years of work experience in a medical environment (such as a hospital, doctor's office, or ambulatory clinic),
  • OR an Associate's Degree AND one year of experience in a medical environment required.
  • Bachelor's Degree preferred.
  • Completion of a medical terminology course (or equivalent) required.
  • Knowledge and interpretation of medical terminology, ICD-10, 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 preferred.
  • Experience utilizing web-based computerized systems preferred.


Licensure, Certifications, and Clearances:

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

 

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, which support the implementation of our diversity strategy. 

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct