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HonorHealth is one of Arizona's largest nonprofit healthcare systems, serving a population of five million people in the greater Phoenix metropolitan area. The comprehensive network encompasses six acute-care hospitals, an extensive medical group with primary, specialty and urgent care services, a cancer care network, outpatient surgery centers, clinical research, medical education, a foundation, an accountable care organization, community services and more. With nearly 14,000 team members, 3,700 affiliated providers and hundreds of volunteers dedicated to providing high quality care, HonorHealth strives to go beyond the expectations of a traditional healthcare system to improve the health and well-being of communities across Arizona. Learn more at HonorHealth.com.
Responsibilities
Job Summary
The Prior Authorization (PA) Specialist is responsible for the review of requests for authorization of services and coordinates the timely completion of the authorization process for Utilization Management Department. The PA Specialist will review referral and admission requests, verify eligibility, benefit information and determine whether sufficient clinical information has been submitted for review utilizing health plan, CMS, MCG or other nationally recognized criteria/guidelines, approves referrals and admission requests if criteria and guidelines are met.
- Receives referral and admission requests from practices and acute/post-acute facilities. Verifies patient's demographic and insurance information within billing system. Coordinates PA process in MCG software and ensures appropriate documentation for criteria is met. Approves request or sends request for the Medical Director/designee review if criteria and guidelines are not met. Maintain a productivity PA case load of an average of 10-15 prior auth processing per day.
- Requests additional information from medical office staff members and referring physicians as necessary
- Identifies potential risk /quality management cases using established criteria and refers to Director. Coordinates PA issues with organization's Medical Director/Designee. Follows organizations PA policies and procedures. Maintains professional conduct and good working relationships with co-workers, supervisors and other provider practices.
- Maintains accurate logs of PA authorizations within software - date stamp all received documents sent to organization for processing. Obtains prior authorizations and referrals from practices in accordance with organization's requirements using website and fax systems. Reviews medical records within IE and/or EPIC for appropriate submission to obtain authorizations.
Qualifications
Education
High School Diploma or GED Required
Experience
1 year health plan based prior authorization experience. Required