Authorization Specialist, Digestive Health Care - Shadyside

UPMC Digestive Health Care Authorization Specialist

UPMC Digestive Health Care is hiring a full-time Authorization Specialist to join their team at Shadyside Medical Building, Pittsburgh! In this position, you will work Monday-Friday, daylight hours.

You will assist with reviewing and interpreting medical record documentation for patient history and diagnosis, submitting and obtaining authorization, scheduling testing and imaging for patients, and other office duties including scanning and faxing. You will also be responsible for authorizations for medications to assist our outpatient and infusion RNs at our Shadyside practice and procedural authorizations for incoming physician Dr. Richie Sun. During downtime we are seeking someone who is capable and willing to be cross trained to assist and to cover Medical Assistant / other positions, as needed with MA, front desk, and scheduling duties.

Purpose

To 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

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.

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 payor to request approval for services being rendered.

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 web sites to perform prior authorization, edit, and denial services.

Utilize 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 with 2 years working experience in a medical environment (such as a hospital, doctor's office, or ambulatory clinic) OR an 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

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

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UPMC is an Equal Opportunity Employer / Disability / Veteran