POSITION SUMMARY The Care Navigation Resource Coordinator – Prior Authorization Specialist performs insurance submissions for prior authorizations for skilled nursing facilities and follow-up of prior authorization within the patient's electronic health record. The position works directly with unit RN Acute Care Navigator(s) and Social Worker(s) providing assistance and support to the care navigation team. The prior authorization specialist collaborates with the care navigation team as well other members of the interdisciplinary team to ensure that patients receive exceptional care and avoid unnecessary delays in discharge. ACCOUNTABILITIES All duties listed below are essential unless noted otherwise Supports ProMedica's mission, "To improve your health and well-being, " as the foundation of employment, vision, and values of the organization in all respects. Demonstrate personally and foster a work environment that includes ProMedica Values: Compassion, Innovation, Teamwork, and Excellence. Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies, and procedures, supporting the organization's corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings. Develops and maintains collaborative working relationships with the Care Navigation team. Develop and maintain collaborative working relationships with key contacts for each payer. Review and maintain familiarity with insurance payer prior authorization guidelines. Initiate the prior authorization with the insurance payer for skilled nursing facility services as required. Follow up with the payer for the authorization determination. Thoroughly review clinical documentation to verify skilled need in accordance with CMS guidelines (Chapter 1 & 8 of Medicare Benefit Policy Manual). Discuss skilled need with CN/SW/and/or Manager as needed. Upload/Fax clinical documentation for skilled nursing facility authorization in accordance with plan requirements such as H&P, PT, OT & ST Evaluation and 1-2 days of most recent notes and other clinically appropriate documentation. Electronic payor portal uploads, faxes, copies, scans EMR information for prior authorization purposes, as appropriate. Provide EHR communication to the care navigation team when additional documentation is required by the insurance to complete or update the submission. Provide peer to peer information or expediated appeal information in a timely manner to care navigation team if an authorization is denied. Thoroughly document submission and determination within the patient's EHR and within the referral management platform. Complete consistent review of individual payer policies to identify changes affecting authorizations. Maintain current knowledge on medical/clinical criteria relating to prior authorization requirements by third party payers and medical necessity requirements. Complete consistent review of individual payor websites/ portals to identify changes affecting prior authorization submission. Participate in process development and process improvement as it relates to prior authorizations, insurance payor communication, education, etc. Provide uninsured, out-of-network and referenced based communication to care navigation team. Additional responsibilities/duties will be assigned based on volume load and competency. REQUIRED QUALIFICATIONS Education: High School Diploma or equivalent; higher post high school education. Skills: Must demonstrate willingness and ability to adapt to change and support progressive movement and process changes. History of positive rapport with patients, families, physicians, and interdisciplinary team. Exceptional problem-solving, critical-thinking, organizational, interpersonal, and written/verbal communication skills. Ability to work in self-directed environment with attention to detail and follow-through. Must be able to multi-task, prioritize tasks and complete work accurately in a fast-paced environment. Computer literate and understanding of Microsoft Office products. Must be able to navigate through the electronic medical record and document properly. Interpersonal skills and the ability to communicate effectively and professionally via phone, email, and in person. Works as a team player with the interdisciplinary team to reach care goals. Performs duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety and a commitment to organization principles. Working knowledge of medical terminology. Ability to work with people of all social, economic, and cultural backgrounds; be flexible, open-minded, and adaptable to change. Ability to work with minimal supervision. Years of Experience: 2-3 years of clerical experience working in a medical setting. License: N/A Certification: N/A WORKING CONDITIONS Personal Protective Equipment: N/A Physical Demands: Frequent sitting and computer use. Onsite or Remote Position: This position is a remote position, allowing the specialist to work from home if they choose. These is also the option to work onsite. This is not a hybrid position. ProMedica is a mission-based, not-for-profit integrated healthcare organization headquartered in Toledo, Ohio. For more information, please visit org/about-promedica Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact . org Equal Opportunity Employer/Drug-Free Workplace Original job Prior Authorization Specialist posted on GrabJobs . To flag any issues with this job please use the Report Job button on GrabJobs. #J-18808-Ljbffr
