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Posted: 06-Feb-25
Location: Rome, Georgia
Categories:
Internal Number: 25004835
Pre Access Authorization Specialist - AdventHealth Georgia
All the benefits and perks you need for you and your family:
- Benefits from Day One
- Paid Days Off from Day One
- Career Development
- Whole Person Wellbeing Resources
- Mental Health Resources and Support
Our promise to you:
Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.
Schedule: Part Time
Shift: Wednesday and Friday 8am – 3pm
Location: 15 JOHN MADDOX DR NW, Rome, 30165
The role you’ll contribute:
The Pre-Access Authorization Specialist, under general supervision, maintains performance standards appropriate to area by obtaining account benefits and/or verifying authorizations are in place for all chemotherapy regimens and treatments, and meeting standards established by leadership for all patient services. Meets or exceeds department audit accuracy and productivity standard goal. Uses utmost caution that obtained benefits, authorizations, and/or pre-certifications are accurate according to the actual test, and procedure or registration being performed. Adheres to AdventHealth Corporate Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies. Actively participates in outstanding customer service and accepts responsibility in maintaining relationship
The value you’ll bring to the team:
- Responsible for review of treatment orders and determines insurance benefits and authorization requirements. Ensures specified medical terms, diagnosis, medication codes and supporting clinical documentations are met. Utilization review to facilitate the sending of clinical information in support of the authorization to payor or third-party administrators, as assigned.
- Reviews medical records in detail to confirm the treatment is supported by approved medical studies. Ensures patient orders are changed accordingly if biosimilar drug is preferred. Ensures that each treatment is coded, reviewed, and financially cleared based on the patient insurance requirements.
- Verifies medical necessity in accordance with Centers for Medicare & Medicaid Services (CMS) standards by reviewing guidelines and communicates relevant coverage/eligibility information to the patient. Alerts physician offices to issues with verifying insurance. Responsible for communicating to service line partners of situations where medical necessity is not met to include review of journal articles, compendia and/or peer review to justify medical necessity approval.
- Reviews clinical records when following up on authorization request directly with a payor. Escalates peer to peer (insurance company physician requests to speak to ordering physician) requests to physician offices and assists in scheduling peer to peer requests with the office and the payer to ensure an authorization decision is made prior to date of service.
- Obtains initial and subsequent pre-authorization for medical treatments, as well as research protocols, on all new and existing patients and notes approvals in the electronic medical record. Uploads treatment supporting documentation packet to the electronic medical record for Revenue Cycle billing and coding teams.
The expertise and experiences you’ll need to succeed:
Minimum qualifications:
- High School Diploma or Equivalent
- 3 years experience
- 1 year experience in healthcare related business operations within specialty pharmacy or insurance verification, payor reimbursement guidelines and/or authorization submission.
- 1 year of direct Patient Access experience
- 1 year of customer service experience
Preferred qualifications:
- Associate's Degree
- 2 years of direct Patient Access experience
- Certified Medical Assistant (CMA)-AAMA
