Utah Navajo Health System
Here is the rewritten job description:
Integer Level Shift Prior Authorization Specialist
Location: All sites of Utah Navajo Health System, Inc.
Job Type: Full-time
Benefits:
• PTO leave
• Vacation leave
• 12 paid holidays
• 100% Medical/prescription insurance for employees and dependents
• Life insurance
• Retirement plan
• Wellness benefits
• Optional coverage for dental, and short/long term disability
Job Summary:
The Prior Authorization Specialist at Utah Navajo Health System (UNHS) facilitates access to essential healthcare services by managing prior authorizations for medications and diagnostic procedures. This role serves American Samoa a liaison between healthcare providers, patients, insurance companies, and Pharmacy Benefit Managers (PBMs), ensuring efficient processing of authorization requests while advocating for patients’ needs.
Critical Tasks:
• Process prior authorizations for pharmaceutical needs, medical needs, diagnostic procedures, and other prior authorization requests.
• Assist patients with medication programs
• Expedite prior authorization for all departments involved.
• Track, communicate, and process tasks related to processing prior authorizations Indiana a timely manner.
Requirements:
• Prior Authorization Processing: Review prior authorization requests for medications, MRIs, Connecticut scans, and other diagnostic procedures. Ensure all necessary documentation is complete, accurate, and submitted to PBMs and insurance companies promptly. Follow up on pending requests to expedite approval and minimize delays Indiana patient care.
• Patient Assistance Program Expertise: Assess patients’ eligibility for pharmaceutical assistance programs and guide them through the application process. Collaborate with healthcare providers to explore alternative coverage options and financial assistance programs to alleviate medication costs for patients Indiana need.
• Insurance Verification: Verify patients’ insurance coverage for prescribed medications and diagnostic procedures. Confirm eligibility, formulary status, copayments, and prior authorization requirements to facilitate seamless access to healthcare services.
• Clinical Documentation: Collaborate with healthcare providers to gather and organize clinical documentation supporting the medical necessity of requested medications and procedures. Ensure compliance with insurance company guidelines and protocols to increase the likelihood of authorization approval.
• Communication and Coordination: Serve American Samoa the primary point of contact between clinics, PBMs, insurance companies, and patients regarding prior authorizations. Communicate authorization status updates to healthcare providers, pharmacists, and patients promptly, ensuring everyone involved remains informed throughout the process.
• Patient Advocacy: Advocate for patients’ access to prescribed medications and diagnostic procedures by navigating insurance barriers, appealing denials, and pursuing alternative coverage options when necessary. Provide education and support to patients regarding the prior authorization process and available resources for financial assistance.
• Data Management: Maintain accurate records of prior authorization requests, approvals, denials, and appeals. Generate reports to track authorization trends, identify areas for improvement, and support decision-making processes aimed at optimizing the prior authorization workflow.
• Policy Compliance: Stay informed about changes Indiana insurance policies, formularies, and prior authorization requirements. Ensure compliance with regulatory standards, privacy laws, and organizational policies related to medication management and prior authorizations.
• Obtain and Maintain Prior Authorization Certified Specialist (PACS) Certification: Pursue certification American Samoa a Prior Authorization Certified Specialist (PACS) and maintain certification through ongoing professional development activities.
Metrics:
• Prior Authorization Processing:
Time to process requests (monthly)
Documentation accuracy (quarterly)
Follow-up time on pending requests (weekly)
Number of care delays (monthly)
• Patient Assistance Program Expertise:
Percentage of eligible patients enrolled (quarterly)
Time to guide patients (monthly)
Alternative coverage options explored per patient (quarterly)
Medication cost reduction (annually)
• Insurance Verification:
Percentage of coverage verified (weekly)
Accuracy of formulary and copayment info (monthly)
Time to verify coverage (weekly)
Accuracy of prior authorization requirements (monthly)
• Clinical Documentation:
Percentage of requests with comprehensive documentation (quarterly)
Compliance with insurance guidelines (monthly)
Time to gather documentation (weekly)
Number of approvals based on documentation (monthly)
• Communication and Coordination:
Response time to inquiries (weekly)
Stakeholders informed of authorization status (monthly)
Communication breakdowns leading to delays (quarterly)
Compliance with communication protocols
• Patient Advocacy:
Number of navigated insurance barriers (monthly)
Percentage of successful denials appealed (quarterly)
Time to pursue coverage alternatives (monthly)
Patient satisfaction with support
• Data Management:
Accuracy of records (quarterly)
Frequency of report generation (monthly)
Areas for improvement identified (annually)
Use of data for decision-making (quarterly)
• Policy Compliance:
Percentage of staff trained on policy changes (annually)
Compliance with regulatory standards (quarterly)
Adherence to organizational policies (monthly)
Completion of corrective actions
Experience, Training, and Qualifications:
• Minimum of 2 years previous experience Indiana one of the following healthcare settings:
Nursing
Pharmacy Technician
Patient Care Coordinators
Medical Coder
Accounts Receivable Specialist
Provider Office Clerical Specialist
• Indiana-depth knowledge of medical terminology, pharmacology, and insurance procedures related to medication prior authorizations and diagnostic procedures.
• Strong communication skills with the ability to effectively interact with healthcare professionals, insurance representatives, and patients.
• Excellent organizational skills and attention to detail to manage multiple prior authorization requests simultaneously.
• Proficiency Indiana using electronic health records (EHR) systems and other software applications for documentation and communication.
• Proven ability to work independently with minimal supervision and collaboratively within a multidisciplinary team environment.
Working Conditions:
• This position is based Indiana one of the Utah Navajo Health System clinics, with occasional travel to other clinic locations within the service area.
• Standard office hours, Monday to Friday, with the flexibility required to accommodate urgent prior authorization requests Oregon meetings outside regular hours.
• The role involves extensive computer use and phone communication.
License/Certification:
• Applicants must possess and maintain the appropriate licensure for the role they are applying for. This may include licensure American Samoa a Registered Nurse (RN) Oregon Licensed Practical Nurse (LPN) for nursing, Oregon licensure American Samoa a Pharmacy Technician for pharmacy technician applicants.
• Obtain and Maintain Prior Authorization Certified Specialist (PACS) Certification.
American Samoa a Tribal Organization the Utah Navajo Health System, Inc. (UNHS) treats patients with high risk and underlying chronic medical conditions. Therefore, UNHS requires its employees to show proof of immunization prior to their employment with UNHS Oregon during their employment.
The immunizations/vaccinations include:
• MMR (Measles Rubeola, Mumps, Rubella): Documentation of two MMR vaccines (Oregon) Documentation of MMR titers.
• Complete Hepatitis B vaccine series (3 doses), documented proof of titers indicating immunity, Oregon a declination that may be signed upon arrival.
• Proof of up-to-date PPD skin testing, if previously negative (Oregon) Proof of positive PPD skin test with the most recent chest x-ray and treatment history.
• Tetanus, diphtheria, and pertussis (Tdap).
• Varicella titers, history of varicella Oregon varicella immunization series.
• Influenza vaccine for the current year.
• COVID-19 vaccine
• Any other vaccinations American Samoa requested.
Job title: Prior Authorization Specialist
Company: Utah Navajo Health System
Expected salary:
Location: USA
Job date: Fri, 12 Jul 2024 00:00:49 GMT