Clinical Pre-Authorization Specialist

Department / Unit :

Patient Engagement Center

Work Shift :

Day (United States of America)Salary Range : Min. $23.96 / hr - Max $38.34 / hr

The Clinical Pre-Authorization Specialist will assist the Patient Engagement Center Liaison, Representatives and other Authorization Specialists with patient clinical questions, payer escalation and triaging patient calls accordingly.

Will work collaboratively with Clinic Nursing Leadership to ensure patient requests and inquiries are managed timely and triage trigger words expeditiously.

Will ensure payers are prepared to reimburse for scheduled services in accordance with the payer-provider contract and works diligently toward the identification, mitigation, and prevention of clinical denials.

In addition to contacting payers and providers via phone, portal or fax, to secure authorizations, this position will use their clinical expertise by reviewing medical necessity, responding to authorization concerns and / or reconciling coverage-related issues.

Responsibilities :

• Will assist Liaison and Representative Teams to triage clinical complaints, trigger symptoms and clinical inquiries appropriately and expeditiously.
• Work collaboratively with Clinic Nursing Leadership to ensure patient is contacted expeditiously same day for trigger word / symptom follow up.
• Uses benefits and order information on file to initiative and secure pre-authorization in advance of service date; excellent knowledge of third party payer authorization portals.
• Communicates with physicians, patients, payers, Patient Engagement Center Representatives and Authorization Specialists to obtain missing demographic information, insurance or clinical information needed to secure authorization for scheduled services.
• Documents all payer communications thoroughly and communicated payer decisions in a timely manner. Manages Medical Necessity as service necessitates and identifies patients needing Medicare Advance Beneficiary Notices (ABNs)
• Assist with the maintenance of Authorization Requirements by Payer database to ensure accuracy by Payer and Product line.
• Reviews clinical denials including those related to pre-authorizations; work with Patient Financial Services in the appeal process based on internal guidelines.

Assists Manager, Pre-Service Operations Authorization and Referral Management in the education of authorization requirements - assists in maintaining Training Manuals and Resources.

• Responsible for review of services being rendered to ensure the appropriate setting of care has been assigned by the physician’s office
• Has ability to organize work with multiple steps to ensure no scheduling or authorization needs are missed.

Qualifications :

Registered Nurse (RN) licensure, preferred.

Thank you for your interest in Albany Medical Center!

Albany Medical is an equal opportunity employer.

This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes.

Workforce members are expected to ensure that :

Access to information is based on a need to know and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose.

Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.