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Prior Authorization Clerk

Cheyenne Regional Medical Center – Cheyenne, WY

ROLE SUMMARYThe clerk will process all health plan/payer utilization review requirements, which include managed care referrals, pre-certifications, and prior authorizations in a timely and accurate manner and act as an authority on referral and prior-authorization criteria and insurance expectations. The clerk will work closely with CRMG physicians, schedulers and staff as well as health care providers, regulatory agencies and payors outside of Cheyenne Regional to assist in facilitating quality patient care, accurate billing and excellent customer service.
CORE RESPONSIBILITIES1. Review all pre-scheduled diagnostic procedures, outpatient therapies, infusions and surgeries on a daily base2. Review all diagnostic and surgery registrations for accuracy. Identify and reconcile all errors3. Verify all diagnostic, procedural and surgical eligibility and benefits for CRMG practices as well as on all workmens compensation and high-risk (e.g., motor vehicle or third party liability). Research electronic medical records to verify appointments are consistent with the pre-authorizaton request and patient is scheduled for correct services4. Obtain and document pre-certification, certification, and/or proper referral during the verification process. Complete all necessary forms and paperwork prior to patients being seen for services5. Communicate effectively with provider offices and payors to ensure authorization and benefits are obtained prior to outpatient services being rendered. Communicate with patients prior to services being rendered if authorizaton was unable to be obtained6. Ensure all insurance information is accurate in electronic medical records, document authorization information in EMR in accordance with approved pre-authorization standards7. Responsible for processing and evaluating physician orders for accurate patient information, physician signature, appropriate diagnosis, and procedure codes. Demonstrate proficient knowledge of online insurance verification systems. Utilize appropriate coding guideline to accurately assign CPT, ICD 9, ICD 10 and HCPCS codes to outpatient procedures8. Double check demographic data for any errors, patient data guarantor data, and reconciling if necessary to avoid problems on bill, communicating changes if necessary to appropriate departments9. Maintain a high level of customer service/satisfaction. This is accomplished by the timely and accurate completion of all duties and meeting pre-defined metrics
DEPARTMENT/ROLE SPECIFIC RESPONSIBILITIESHome Care: Follow up on the status of unsigned orders, help with the management of medical records, answer phone calls, and ensure prior authorization for home care programs.
The above statements are intended to describe the general nature and level of work performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required of personnel so classified and employees may be required to perform other duties as assigned.
  • Requires excellent verbal, written and interpersonal communication skills with providers, colleagues, patients and other management.
  • Ability to assess, evaluate, explain, teach, and problem solve using critical thinking and knowledge of basic office functions.
  • Knowledge of medical terminology and clinic focused health care
  • Strong knowledge of the pre-authorization and referral processes
  • Knowledge of both government and a non-government payer requirements
  • Demonstrates a basic understanding of hospital insurance contracts to determine if treatment and services are covered by insurance at facility
  • Demonstrates an independent work initiative, sound judgment and attention to detail and the ability to handle multiple tasks simultaneously
  • Proficient with standard office equipment and software

  • High School Diploma or GED
  • Coding experience
  • Minimum of two years experience in prior authorizations and referrals
  • Knowledge of health care and medical practices

  • Associates degree in Nursing, HIT program, or other Healthcare-related program
  • Coding Certification
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