Prior Authorization Rep Sr, Financial Securing
We are currently seeking a Prior Authorization Representative Senior to join our Financial Securing team. This full-time role will primarily work remotely (Days M-F). The Prior Authorization Specialist plays a key role in the patient financial experience by coordinating pre-authorizations for patients and often handling cases that need quick turnaround (e.g., last-minute scheduled services). The individual in this role is an expert on payer regulations and contracts, and they serve as a point of contact for peers looking to resolve questions or issues regarding prior authorizations.
Current List of non-MN States where Hennepin Healthcare is an Eligible Employer: Alabama, Arizona, Arkansas, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Mississippi, Nevada, North Carolina, North Dakota, New Mexico South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin.
Responsibilities
- Utilizes online systems, phone communication, and other resources to secure prior authorizations within a timeframe before scheduled appointments/procedures/same day surgeries and during or after care for unscheduled patients.
- Verifies medical necessity in accordance with the Centers for Medicare & Medicaid Services (CMS) standards and communicates relevant coverage/eligibility information to the provider/patient, as it pertains to prior authorization.
- Coordinates benefits by effectively determining primary, secondary, and tertiary liability when needed.
- Obtains pre-certifications and prior authorizations from third-party payers in accordance with payer requirements.
- Alerts physician offices to issues with verifying insurance and/or obtaining prior authorizations.
- Demonstrates expert understanding of insurance terminology (e.g., co-payments, deductibles, allowances, etc.), and analyzes information received to determine patients' out-of-pocket liabilities, based on prior authorization status.
- Follows up on all prior authorization submissions for timely response.
- Follows up on any prior authorization denials; assists Utilization Management with appeals, as needed.
- Connects patients with financial counselors, as necessary.
- Maintains productivity and quality standards and assists other team members when necessary.
- Participates in developing and planning process improvements for the department.
- Other duties as assigned.
- Complies with all state and federal laws and regulations related to patient privacy and confidentiality.
Qualifications
Minimum Qualifications:
- High school diploma or equivalent.
- 2 years clerical experience in health care revenue cycle operations: billing/claims, patient accounting, collections, admissions, registration, etc.
- Bilingual strongly preferred, required in some positions -OR- An approved equivalent combination of education and experience.
Preferred Qualifications:
- Experience working in EPIC, preferred.
Knowledge/ Skills/ Abilities:
- Requires knowledge of government and commercial payer (Insurance) benefit and eligibility verification, and ability to become aware of and navigate medical policy per payer guidelines.
- Demonstrated expertise in logical thinking, data preparation, and analysis.
- Comprehensive knowledge of Microsoft Office (Outlook, Word, Excel).
- Strong communication skills, both verbal and written.
- Ability to communicate effectively with collaborating departments, providers, and insurance representatives.
- Demonstrated organizational skills and the ability to prioritize and manage tasks based on established criteria.
- Excellent verbal and written communication and interpersonal skills.
- Ability to work independently with minimal supervision, within a team setting and be supportive of team members.
- Proficient with Microsoft Office.
- Ability to analyze issues and make judgments about appropriate steps toward solutions.
Location: MN-Minneapolis-Downtown Campus