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Prior Authorization Specialist (9564)

Company: Regency Integrated Health Services
Location: Weslaco
Posted on: May 3, 2021

Job Description:

Job Summary

The Prior Authorization Specialist supports the admissions department's activities in the pre-admission, admission and follow up processes.


Essential Functions:

* Receives prospective resident referral and reviews financially and clinically with supporting tools. i.e. clinical and managed care grids * Initiate prior authorization requests for various insurance companies through their preferred method (I.E. call in, fax, online). * Coordinates the assignment of attending physician for prior authorization * Provides NPI/Tax ID * Obtains prior approval number from payer on a per case basis when authorized * Communicates potential risks to Central Admissions Specialist (CAS) * If specialized equipment or high cost medications is ordered, must initiate carve out to reduce facility cost * Locate correct ICD 10 code for authorization * Verify all patient, facility, and contact information given are correct prior to submitting information to the insurance company * Daily follow up on prior authorization requests that are still pending * Complete Managed Care Flow Sheet documenting the representative, reference number, date and time noting the initial contact and follow up calls that were placed * Provide CAS & accepting facility with authorization number, approval dates, next review date and insurance representative contact * Return packet to CAS once authorization is received * Reviews computerized census system daily * Access continuing education opportunities appropriate to responsibilities * Promotes optimal communication among program staff members, facility staff, referrals sources, physicians and residents * Appropriately accesses the resources of the company's regional offices for consultation and program development support * Seeks out external resources through conferences, workshops, etc. as necessary. Routinely shares personal knowledge with staff, other managers and facility personnel * Demonstrates flexibility in adjusting to change, patient needs, and customer expectations; meets company standards relating to deadlines and attendance * Establishes and maintains exemplary standards for department appearance and staff presentment; ensures compliance with company and facility policies and procedures * Adheres to all safety and risk management protocols and programs * Participates in quality improvement activities, which reduce cost and increase efficiency through improved systems and processes * Exhibits courtesy, compassion and respect to residents, families, visitors, physicians, administrators and coworkers * Performs other duties or functions as directed



* Licensed Vocational Nurse is required * At least one year experience in Health Care Sales/Marketing/Insurance or commensurate education preferred * Familiar with medical terminology


A Prior Authorization Specialist should have some knowledge, skills and abilities in order to properly do his or her job. Among them, we indicated the following as requirements:

* Communication: taking with healthcare workers, doctors, nurses, families and patients on a daily basis, must be friendly and able to listen to needs and concerns * Empathy: working with people who may be injured, infirmed, or confused and their families, understanding needs and concerns is crucial * Detail orientated: working with medical records and must organize and process this information for use in the facility and with referring facilities * Technical skills: using computers to input data and may need to use coding and classification software and electronic health record systems

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and hear. Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus.

75% Standing

50% Using Hands to Finger, Handle, Feel

75% Lifting: Up to 10 Pounds (Frequent)

75% Walking

15% Reaching with Hands and Arms

25% Lifting: Up to 25 Pounds (Occasional)

25% Sitting

15% Climbing or Balancing

15% Lifting: Up to 50 Pounds (Occasional)

100% Talking

15% Stooping, Kneeling, Crouching, or Crawling

0% Lifting: Over 50 Pounds

100% Hearing/Listening

15% Pushing, Pulling (Occasional)

100% Other: Seeing, Speaking

Keywords: Regency Integrated Health Services, Edinburg , Prior Authorization Specialist (9564), Other , Weslaco, Texas

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