Position:  Prior Authorization/Referral Rep  

Department: Consulting Services

Reports To: Director- Consulting Services

Direct Reports:  None

FLSA Classification:  Non-Exempt

Position Summary

The Prior Authorization rep is responsible for providing indirect patient care through completion of practitioner ordered referrals and prior authorizations. Works closely with insurance companies to obtain authorization prior to scheduled surgeries and tests to ensure proper payment for such procedures. Establishes appointments for patients needing referral to an outside facility for continuation of care and/or specialty care. Supplies additional required information as needed to insurance companies and facilities to complete required tasks. Responds quickly and accurately to assist with referral and prior authorization tasks.   

General Duties, Tasks and Responsibilities

• Follows medical records documentation guidelines regarding timeliness of reviews and completeness of documentation; obtains and documents accurate and thorough patient medical history including pertinent history, pain assessment, current medications, identified health risk factors and other needed information.
• Completes pre-certification for testing/procedures; ensure notification of pre-certification for each patient is completed in a timely manner.
• Assists outside clinics with courier duties, including collecting specimen samples from the satellite clinics and delivering and collecting supplies/mail. 
• Performs all aspects of the position in an environment that optimizes patient safety and reduces the likelihood of medical/healthcare errors; utilizes established hand-off communication protocols; maintains the security of the department.
• Obtains proper authorization; follows medical records documentation guidelines regarding timeliness of reviews and completeness of documentation.
• Works with patient to establish a referral appointment for the specialty or facility indicated by the ordering practitioner.
• Provides supplemental information to insurance companies and practitioners/facilities to obtain pre-certification or a referral appointment.
• Communicates established appointments and details with patients upon completion of a referral appointment.
• Completely and accurately documents all communication with insurance companies, facilities, and patients.
• Complies with all established safety procedures to ensure a safe environment for patients, visitors and staff.
• Participates in performance improvement activities 
• Performs other duties as assigned

Education Requirements

• High School diploma / Equivalent Required
• Completion of an accredited Medical Assistant Program or HIM Degree/Certificate preferred

Certification/Licensure Requirements

• Current (CCMA) Medical Assistant Certification or HIM Degree/Certificate preferred
• BLS preferred

Experience Requirements

• CCMA/HIM minimum 1 year Preferred
• Physician Office minimum 2 years Preferred

Computer Skills

• Strong computer skills including Microsoft Excel and Outlook

Additional Skills

• Excellent communication and customer service skills
• Strong interpersonal, organizational and time management skills
• Ability to work independently, prioritize and complete tasks in a timely manner