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Sr. Authorization Specialist

  • Job ID: 189470408
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: Corporate Revenue Cycle
  • Department: Rev Cyc Care Mgmt
  • Location: 2 Hot Metal Street, Pittsburgh PA 15203
  • Union Position: No
  • Salary Range: $17.39 to $27.61 / hour

Description

Purpose:

Do you have experience with claims and authorizations?  Are you looking to grow your career?  UPMC is hiring a full-time Sr. Authorization Specialist to support its Revenue Cycle department.  This position is eligible to work from home, however rotation into the office at the Quantum One Building is required every 3 weeks.  This role would work Monday though Friday during daylight hours.

In this role, The Sr. Authorization Specialist will perform all authorization activities for inpatients, outpatients, and emergency department patients, including actions for both prior authorization and retrospective authorization.  They will also handle denial management.  The employee must complete their job responsibilities in a timely manner.

If you are excited about the challenge, apply online today!



Responsibilities:

  • 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.
  • 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.
  • 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.

 

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:

UPMC is an Equal Opportunity Employer/Disability/Veteran

Total Rewards

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