Pre-Authorization Specialist I

About the position The Pre-Authorization Specialist is an essential role responsible for facilitating exceptional patient experience, by securing authorizations for all scheduled services related to medical and surgical admissions across entities. This is a role that is critical to the organization’s financial health. The duties consist of obtaining pre-authorizations for at least one modality in outpatient medical imaging, outpatient surgeries, special procedures, Heart & Vascular, Interventional Radiology, Pain Management, OB Services, scheduled admissions or genetic lab testing. The position requires the ability to independently plan, schedule and organize numerous tasks as this position directly impacts hospital and physician reimbursement. This position plays a critical role in supporting Augusta Health’s mission and advancing departmental goals through measurable performance indicators and service excellence. This position contributes to a collaborative, patient-centered environment and helps drive outcomes aligned with organizational priorities.

Responsibilities

• Generates and monitors worklists to ensure all scheduled appointments are properly reviewed and pre-authorizations secured in accordance to standard and expectation.
• Verifies insurance coverage, collecting, and documenting insurance benefits and authorization requirements and procuring necessary authorizations for medical services and outpatient services according to patient insurance protocols using available tools and insurance portals.
• Acts as a subject matter expert in insurance benefits and authorization requirements.
• Obtains pre-certification for scheduled inpatient admissions electronically via insurance portals or telephone. Ensures that authorizations for outpatient surgeries, special procedures, outpatient Medical Imaging, Outpatient Surgery, Special Procedures, H&V, Cath Lab, Interventional Radiology, Pain Management, and other services, as assigned, are obtained per timeline protocols. Documents and scans insurance authorization information in the appropriate fields within the computer system.
• Verifies all of the components of the authorization are correct including the facility, provider, CPT code, admission type, NPI, TIN and effective dates.
• Accesses, analyzes, and selects relevant patient clinical information based on procedure codes (CPT) and diagnosis codes (ICD-10) to submit to insurance companies to support pre-authorization requests.
• Works closely with Financial Advocates and/or Patient Access leaders to offer financial options such as upfront payment, payment plans, MDSave, and/or financial assistance for patients who do not have insurance coverage or who had pre-authorizations denied by their insurance carriers.
• Reports denials and pending authorizations for scheduled services to management to determine proper plan of action.
• Obtains retro authorizations for services, updates patient accounts with the retro authorization information, and communicates with the Billing Department to have claims submitted to insurance companies for reprocessing.
• Provides regular feedback to management related to payer issues, provider office issues, and any other issues that will delay obtaining authorization
• Contacts insurance companies, managed care plans, outside agencies, and intermediaries to verify insurance coverage and benefits. Determines if any pre-admission/pre-visit requirements exist, e.g., predetermination of medical necessity, need for out of network plan auth required in addition to the service/procedural auth, etc.
• Ability to identify incomplete clinical documentation that is needed to obtain approval for services. Interacts directly with physicians/clinicians/physicians’ office staff via Athena, phone calls and Outlook to identify what is missing and to collect further complete and appropriate patient data and clinical information necessary to submit to Medical Insurance to review for authorization of services scheduled.
• Monitors pending cases to ensure that approvals are obtained prior to admission or visit.
• Informs doctor’s office of any additional clinical requested, including notes that are lacking tried and true therapies/refrainment, e.g., Imaging, Orthopedic or Neuro Spine cases.
• Assists reimbursement team in authorization related corrections on rejected or denied claims.
• Obtain retro authorizations on billed and rejected claims and denied procedure codes for facility. Initiate appropriate follow-up actions in response to information obtained and document outcomes for appeals as needed.
• All other duties, as assigned

Requirements

• High School Diploma or GED equivalent
• 1-year previous experience in patient/customer-facing role
• Eligibility to work in the United States and meet Virginia state employment requirements
• Basic knowledge of insurance requirements
• Good computer skills

Nice-to-haves

• Associate's degree
• CHAA certification with the National Association of Healthcare Access Management (NAHAM), can be obtained on the job.
• AAPC Medical Coding Certification
• Knowledge of CPT and ICD-10 coding
• Medical Terminology
• Previous experience in hospital, healthcare practice, or health insurance company, Pre-authorization Specialist, Insurance Specialist, or similar
• Prior experience in a hospital, healthcare system, or related service-oriented environment
• Familiarity with Augusta Health’s systems, workflows, or organizational culture is a plus
• Good interpersonal communication skills and positive attitude
• Organization, prioritization, and problem-solving skills
• Self-starter, ability to work with minimal supervision
• Adaptable to change
• Experience and competent in customer relation skills in a professional environment
• Experience in Microsoft Office products
• Effectiveness as a member of a team and be self-directed
• Articulates knowledge and understanding of organizational policies, procedures, and systems
• Ability to effectively work in a remote environment and connect via multiple communication channels (phone, email, text, etc.)
• Clearly and thoroughly document all actions, contacts, outcomes, and interventions

Benefits

• Comprehensive insurance package including medical, dental, and vision coverage
• Retirement savings plans and financial wellness support programs
• Generous paid time off and flexible scheduling to promote work-life balance
• Career development programs including clinical ladders, shared governance, and advancement opportunities
• Personalized onboarding with dedicated preceptors and ongoing educational support
• Tuition reimbursement and access to onsite childcare
• Free onsite parking, 24/7-armed security for your safety, a Health Fitness Reimbursement Program, and an onsite credit union and pharmacy
• Competitive pay with shift/weekend differentials
• Employee discounts at the cafeteria, gift shop, pharmacy, and local entertainment venues (i.e., movie tickets)

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