Description :

1. Responsible for ensuring the appropriate use of selected prescription drugs to promote patient safety and adherence.
2. Responsible for preventing the improper prescribing or use of certain drugs through thorough analysis and intervention.
3. Responsible for coordinating and communicating with doctors to prescribe an alternate drug beneficial for the patient, ensuring optimal treatment outcomes.
4. Responsible for processing prior authorization requests for various medical procedures, prescription drugs, and treatments within a high-volume environment, maintaining an approval accuracy rate that meets or exceeds industry standards.
5. Responsible for reviewing clinical documentation to determine eligibility for coverage based on health plan policies, medical necessity criteria, and regulatory guidelines, ensuring compliance and accuracy.
6. Responsible for collaborating with healthcare providers, pharmacists, and insurance carriers to resolve complex cases, resulting in an average reduction in processing time and improved patient satisfaction.
7. Responsible for utilizing electronic medical record (EMR) systems and prior authorization platforms such as specific systems: CoverMyMeds, and NaviNet to streamline operations and ensure compliance with industry standards and best practices.

Experience

2-5 Years

Level

Junior

Education

Health Administration

Description :

1. Contacted patients to achieve established outreach program goals, ensuring effective communication and follow-up.
2. Utilized telephone, email, and direct mailings to emphasize the clinical importance of receiving recommended lab work and attending medical appointments.
3. Scheduled appointments in the electronic medical record system to streamline patient care.
4. Leveraged Healthy Planet Registry in Epic EMR to identify patients needing additional labs and those overdue for labs.
5. Consulted with clinicians to determine required population reports andor patient lists for analysis and outreach.
6. Communicated and collaborated with care coordination staff to optimize patient care, and supports patient care plans by assisting with linkages to, coordination of, and monitoring identified service needs.
7. Recognized and reported data inconsistencies, gaps in performance, and opportunities to improve results to appropriate personnel.

Experience

2-5 Years

Level

Junior

Education

Medical Billing and Coding

Description :

1. Worked with the PA from beginning to end, communicating with our external customers and insurance carriers to verify insurance eligibility with various government and commercial insurance carriers. 
2. Documented patient demographics and insurance information will lead to your success in this position. 
3. Worked directly with insurance carriers to document specific carrier prior authorization requirements and processes. 
4. Followed up on Prior Authorization approvals and denials.
5. Clearly and concisely explained and educated the components of laboratory testing and billing guidelines to the clients, sales representatives, and patients.
6. Maintained relationships with clients with a high level of service and knowledge.
7. Ensured that patient demographics, insurance information, verification, and eligibility have been established and documented.

Experience

2-5 Years

Level

Junior

Education

Healthcare Management

Description :

1. Maintained accurate records of patient billing transactions, prior authorization requests, and benefit verifications.
2. Sought to leverage expertise in specific tools software and knowledge of healthcare policies to contribute to the success.
3. Evaluated requests for medical procedures, services, or prescription drugs by assessing clinical documentation, health plan policies, and regulatory requirements.
4. Checked patient eligibility and benefits based on their insurance plan, ensuring the requested services complied with coverage guidelines.
5. Analyzed medical records and clinical documentation to determine if the requested services or medications meet medical necessity criteria.
6. Collaborated with healthcare providers, physicians, and pharmacists to gather additional information, clarify documentation, or resolve discrepancies in authorization requests.

Experience

2-5 Years

Level

Junior

Education

Public Health

Description :

1. Used electronic health records (EHR) systems and prior authorization software (CoverMyMeds, NaviNet) to process and track authorizations, ensuring accurate documentation.
2. Reviewed denied requests, providing detailed explanations to healthcare providers. 
3. Assisted with appeal processes by submitting additional documentation or medical justifications when appropriate.
4. Ensured that all requests adhere to applicable regulations, such as Medicare, Medicaid, and commercial insurance policies, while maintaining compliance with HIPAA and other regulatory standards.
5. Maintained an organized system for tracking prior authorization requests and their statuses, ensuring timely approvals or resolutions to avoid treatment delays.
6. Addressed any potential barriers to the approval process, including incomplete documentation, coding errors (CPT, ICD-10, HCPCS), or discrepancies in patient information.
7. Offered clear communication and assistance to patients, healthcare providers, and insurance companies regarding the status and outcome of authorization requests.

Experience

5-7 Years

Level

Executive

Education

Health Administration

Description :

1. Recorded decisions, approvals, and denials in internal systems. 
2. Prepared reports on authorization trends, turnaround times, and areas for process improvement.
3. Kept current with changes in healthcare regulations, insurance coverage policies, and clinical guidelines to ensure compliance and accuracy in the authorization process.
4. Managed the review and approval process for medical treatments, procedures, and medications to ensure they were covered by insurance and met clinical and regulatory requirements. 
5. Understood healthcare insurance policies, MedicareMedicaid regulations, and private-payer guidelines.
6. Coded systems such as CPT, HCPCS, and ICD-10 for accurately interpreting clinical documentation.
7. Understood medical terminology, treatment protocols, and clinical documentation to assess the appropriateness of requested services.

Experience

7-10 Years

Level

Management

Education

Health Informatics

Description :

1. Evaluated requests for medical services, treatments, and prescription medications to determine if they meet medical necessity and coverage criteria.
2. Confirmed patient insurance benefits and coverage details to ensure that the requested services are eligible for prior authorization under the patient's insurance plan.
3. Analyzed clinical data, identify patterns, and make informed decisions regarding prior authorization approvals or denials.
4. Reviewed clinical documentation, insurance policies, and prior authorization requests to avoid errors or delays.
5. Interacted with healthcare providers, patients, pharmacists, and insurance representatives.
6. Worked with billing departments, case management, and pharmacy teams to resolve authorization-related issues and ensure the smooth processing of claims.
7. Created and analyzed reports on authorization activity, trends, and turnaround times, identifying areas for improvement in the authorization process.

Experience

7-10 Years

Level

Management

Education

Pharmacy

Description :

1. Explained authorization decisions and resolved disputes or clarified documentation requirements.
2. Focused on providing a positive experience for healthcare providers and patients by ensuring clear communication and timely processing of authorizations.
3. Managed a high volume of authorization requests efficiently, meeting deadlines, and ensuring timely follow-up on outstanding cases.
4. Worked effectively with healthcare teams, case managers, pharmacists, and insurance companies to resolve complex cases.
5. Used Microsoft Office Suite (Excel, Word, Outlook) for documentation and reporting.
6. Communicated with physicians, pharmacists, and other healthcare professionals to obtain necessary clinical documentation, clarify requests, or provide guidance on the prior authorization process.
7. Generated reports on authorization trends, turnaround times, and process improvements based on data from authorization systems.
8. Conducted thorough reviews of prior authorization requests to ensure compliance with established medical guidelines and insurance policies, resulting in a significant reduction in approval times.

Experience

10+ Years

Level

Senior

Education

Nursing

Description :

1. Ensured that medical treatments, procedures, and medications are approved by insurance providers according to established policies and guidelines.
2. Ensured that these requests met medical necessity, insurance coverage guidelines, and regulatory compliance. 
3. Involved communication with healthcare providers, insurance companies, and patients to ensure timely approvals and resolution of any issues that may arise.
4. Assessed prior authorization requests for medical services, treatments, or prescription medications by analyzing clinical documentation and insurance policies.
5. Managed time effectively and prioritized tasks in a high-volume environment.
6. Helped healthcare organizations ensure that services are approved in compliance with insurance policies and regulations.
7. Evaluated medical records and clinical data to ensure that requested treatments met medical necessity criteria as outlined by insurance companies and healthcare plans.

Experience

10+ Years

Level

Senior

Education

Health Policy

Description :

1. Utilized electronic prior authorization platforms (CoverMyMeds, NaviNet) and EHR systems (EPIC, Cerner) to process and document authorization requests accurately.
2. Served as a liaison between healthcare providers and insurance carriers, requesting additional documentation when needed and resolving discrepancies to ensure accurate authorizations.
3. Analyzed denied requests, provided justifications for denials, and assisted with the submission of appeals when appropriate, ensuring all necessary documentation was provided.
4. Stayed current with healthcare regulations, including HIPAA, Medicare, Medicaid, and commercial insurance policies, ensuring all processes adhere to legal and regulatory standards.
5. Maintained organized records of pending, approved, and denied prior authorizations. 
6. Ensured timely follow-up on outstanding requests to prevent delays in patient care.
7. Responsible for monitoring and tracking authorization status, ensuring timely communication with all stakeholders involved in patient care.

Experience

10+ Years

Level

Senior

Education

Medical Office Administration