Pt Svc Rep 1/Prior Auth Spec- CWP Endo

• Assists department leadership to optimize and implement current prior authorization workflow, procedures, documentation, and communication.
• Stays informed and researches new information as needed regarding LCDs, NCDs, formulary lists, and specific insurance criteria necessary to obtain prior authorization and reimbursement for services provided within endocrinology specialty.
• Educates and communicates with providers and clinical staff regarding the above information to help facilitate optimum patient treatment plans, documentation, and payment of services.
• Ability to navigate and maneuver through multiple web sites
• Keeps current, organized, and detailed information needed to complete this role in one location either on paper or in an electronic file.
• Collaborates with clinical integration and endocrinology team to optimize and standardize EMR documentation identifying prior authorization needs, medical necessity detail, and other criteria surrounding such authorizations.
• Seeks assistance when required for clinical expertise with insurance verification or other patient/provider needs.
• Serves as primary resource to patients regarding prior authorization process.
• Demonstrates ability to complete work with a high level of detail and accuracy.

• Receives requests for prior authorizations.
• Validates patient coverage, benefits and eligibility.
• Demonstrates ability to work efficiently, independently, prioritizing authorizations based on patient needs and department procedure schedules.
• Initiates Prior Authorization request to insurance carriers and/or primary care physicians in accordance with specific payer processes (website, fax, phone).
• Ensures accurate ICD, CPT codes and related medical records are submitted in the authorization request.
• Creates detailed documentation and maintains/stores the authorization 'paper trail'.
• Follows-up on and completes prior authorization requests.
• Informs providers and their clinical staff when issues arise relating to obtaining prior authorization.
• Communicates with patients regarding authorization status.
• Demonstrates a professional image in dealing with team members, providers, patients, families and payors.
• Verifies and accurately documents third party responses to authorizations in the EMR.
• Follows up on delayed or denied authorization requests, gathers additional clinical/coding information, as necessary, submits appeals or escalates appropriately for resolution while meeting specified deadlines as required by said third party.

• Reconciles daily patient charges for accuracy.
• Assists patients to estimate costs prior to patient appointments according to department guidelines including insurance portions and self-pay estimates.
• Works to resolve claims/denials related to the prior authorization.
• Takes ownership of the patient account work queue (requires working with providers and CBO patient account representatives and coding team to correct charges and/or billing issues). Completes these accounts in a timely manner.
• Completes other department duties as assigned by immediate supervisor.

• Answers phones
• Schedules appointments
• Maintains workques
• Patient registration
• Checking in and out patients

Find it here.

Discover the job, the career, the purpose you were meant for. The supportive and inclusive team where you can thrive. The place where growth meets balance - and opportunities meet flexibility. Find it all at Carle Health.

Based in Urbana, IL, Carle Health is a healthcare system with nearly 16,600 team members in its eight hospitals, physician groups and a variety of healthcare businesses. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet designations, the nation's highest honor for nursing care. The system includes Methodist College and Carle Illinois College of Medicine, the world's first engineering-based medical school, and Health Alliance. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: human.resources@carle.com.