Referral and Pre-Authorization Specialist
Job location: Charlottesville, VA
Employment Type: Full-time
Posted data: 2021-01-05
Responsible for obtaining approval of professional and technical services which may include obtaining insurance referrals, procedures authorizations, or pre-certifications required for patients to receive physician services, medical procedures, equipment, supplies and medications.
- Obtain referrals, authorizations and pre-certifications through a work queue process flow and EPIC lists to ensure required approvals are obtained within an established time standard.
- Review and evaluate documentation of Electronic Medical Records (EMR) record to obtain medical necessity, clinical data for approvals.
- Ensure referrals are attached to appointments, and the appropriate insurance information is documented. Research and update insurance carrier requirements as necessary.
- Assess the documentation to assign appropriate CPT procedure and ICD code to accurately report the physician services.
- Collaborate with referring and/or ordering provider across UVA departments to obtain information to support medical necessity and accurate coding.
- Coordinate appointment and authorization information to in and out of network entities that provide care to include hospital systems, clinics, specialists, equipment suppliers, manufacturers, and pharmacies.
- Communicate and coordinate with patient the scheduling of diagnostic and specialty appointments, tests, procedures, insurance coverage, and patient financial responsibility. Obtain as necessary waivers for non-covered services. Review financial assistance options as applicable.
- Document in EMR all required and support information to ensure providers, insurance companies, pharmacies and staff have appropriate information to approve, provide care and perform accurate billing.
- Collaborates with ordering provider, manager and staff to address denied authorizations. Facilitates discussion between provider and insurance company of request to change orders, appeal process, and peer to peer review. Completes form or electronic process for appealing denials per payor guidelines.
- Manage verbal, electronic and written inquiries from pharmacists and providers regarding authorizations for prescribed medication.
- Facilitate resolution of medication coverage issues and proactively address, research, and resolve issues to include early release, quantity and dosage, generic equivalent, and treatment options.
- Performs other duties as assigned.
High School Diploma or GED
Three years experience with preauthorization and referral processing.
Knowledge and skills:
Incumbent should have an in-depth knowledge of CPT and ICD coding.
In-depth knowledge of Medicare, Medicaid and third-party payers and pre-authorization requirements.
Basic pharmacological knowledge and understanding of drug formularies.
Understanding of human anatomy, medical terminology and procedures.
Strong computer skills including use of Microsoft Office (Word and Excel), electronic mail, and EMR.
Strong analytical, prioritization and organizational skills.
Ability to work independently with minimal supervision and to manage multiple priorities.
This is primarily a sedentary job involving extensive use of desktop computers. The job does occasionally require traveling some distance to attend meetings, and programs.
The University of Virginia, including the UVA Health System which represents the UVA Medical Center, Schools of Medicine and Nursing, UVA Physician’s Group and the Claude Moore Health Sciences Library, are fundamentally committed to the diversity of our faculty and staff. We believe diversity is excellence expressing itself through every person's perspectives and lived experiences. We are equal opportunity and affirmative action employers. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran status, and family medical or genetic information.