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Job Details

Pre-Authorization Specialist

Department: Registration Center - CFH_10_19
Usual Schedule: 8a-5p
Regions: Carle Foundation
On Call Requirements: No
Job Category: Clerical/Admin
Work Location: Carle at The Fields
Employment Type: Full - Time
Nursing Specialty:
Job Post ID: 45275
Secondary Job Category:
Experience Requirements: 1 - 3 Years
Weekend Requirements: No
Education Requirements: HS Diploma/GED
Shift: Day
Location: Urbana, IL
Holiday Requirements: No
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Check out this job opening for Carle Providers: Pre-Authorization Specialist Check out this job opening for Carle Providers: Pre-Authorization Specialist


Job Description

JOB SUMMARY:
The Pre-Authorization Specialist is responsible for identifying prior auth requirements by insurance/payer and processes and completes prior authorizations for scheduled and add on services. Determines if services are a covered benefit and documents pre-authorization information in Epic. Communicates with the ordering Provider's office if services were approved or denied to reduce denials and facilitates peer to peer reviews when needed.

EDUCATIONAL REQUIREMENTS
Associates degree or NAHAM Certification

CERTIFICATION & LICENSURE REQUIREMENTS
Completion of Medical Terminology course within one (1) year of start date in position.

EXPERIENCE REQUIREMENTS
Healthcare/Insurance experience of one (1) + year preferred

SKILLS AND KNOWLEDGE
Strong verbal and written communication skills. Adept at learning and using software programs is essential. Demonstrated ability to organize and prioritize work and possess a strong attention to detail and follow up with minimal direction/supervision. Ability to work and collaborate with patients, nurses and physicians under stressful situations. Able to work independently and apply critical thinking skills when dealing with insurance scenarios for various payers. Able to navigate multiple payer websites to ensure requirements are met. Ability to handle large volume of pre-auths and multi task concurrently.


ESSENTIAL FUNCTIONS:
  • Analyzes information required to complete pre-authorizations based on multiple insurance/payer requirements; ensures coverage/insurance is correct.
  • Proficiently utilizes third party payer/insurance portals to process pre-auth submissions; has a detailed knowledge of insurance providers, their portals and expectations for authorization approval.
  • Documents pre-authorization results completely and communicates to leadership, Providers and/or Nurses pre-authorization approvals or denials.
  • Advocates for patients/providers by processing pre-auths in a time sensitive manner and collaborating with physicians and nurses to secure clinical information needed for submissions.
  • Identifies challenges, trends and patterns and works with management to address and resolve.
  • Other duties as assigned.
  • Identifying prior auth requirements by insurance/payer and processes and completes prior authorizations for scheduled and add on services.
  • Determines if services are a covered benefit and documents pre-authorization information in Epic.
  • Communicates with the ordering Provider office if services were approved or denied to reduce denials and facilitates peer to peer reviews when needed.



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All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. We are committed to creating a diverse and welcoming workplace that includes partners with diverse backgrounds and experiences. We believe that enables us to better meet our mission and values while serving customers throughout our communities. People of color, women, LGBTQIA+, veterans and persons with disabilities are encouraged to apply. Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal state and local ordinances. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: human.resources@carle.com. Positions are not available for remote work in the state of Colorado.

Effective September 20, 2021, the COVID 19 vaccine is required for all new Carle Health team members. Requests for Medical or Religious exemption will be permitted.

 

Illinois Required Notices

Federal Required Notices