Prior Authorization Manager (inpatient/outpatient services)
Fairfield-IA-52556-United States
POSITION OVERVIEW:
The Prior Authorization Manager oversees the daily operations of the Prior Authorization department, ensuring compliance with regulatory guidelines and optimizing revenue cycle activities. This role is responsible for securing prior authorizations for inpatient and outpatient services, diagnostic imaging, labs, and procedures while maintaining high-quality customer service. This role will act as liaison between a multifunctional centralized department with staff in multiple locations with dotted lines to the Prior Authorization Manager.
QUALIFICATIONS:
LPN/RN preferred or bachelor’s degree in business management
Minimum of 5-years of experience in Prior Authorization/Pre-certification
Proficient in clinical practices, prior authorization processes and coding basics
Experience with Insurance company medical necessity rules as well as prior auth processes
Experience with automated systems and strong knowledge in PC Programs, MS Office and Web-based programs and research required.
Experience and knowledge of billing, denial management, and researching coverage policies and procedures.
This individual needs a combination of technical, administrative, and interpersonal skills to effectively oversee authorization processes in a hospital or healthcare setting.
ACCOUNTABILITY:
Revenue Cycle Director
DIRECT REPORTS:
yes
POSITION-SPECIFIC REQUIREMENTS:
- Serves as the point of contact for addressing questions and process development for the department, working departments, and the business office
- Verify that the service is a covered benefit based on knowledge of the specific insurance plan and benefit package restrictions.
- Understand patient deductibles, out-of-network referrals, out-of-pocket limitations, and lifetime/event caps on liability.
- Responsible for training and onboarding staff including any credentialing needed.
- Participates and attends all required meetings and in-services.
- Maintains and expands current knowledge of rules and regulations of industry and government programs, hospital financial and billing policies, and educates other staff as necessary.
- Follows HIPAA regulations and ensures that the confidentiality of patients’ medical, personal, financial records, employee records and organizational records is maintained.
- Makes reasonable efforts to limit the use and disclosure of (PHI) Protected Health Information to the Minimum Necessary to perform job.
- Responsible for Compliance and upkeep of established policies & procedures and directives from the Director.
- Position requires being available during business hours, Monday through Friday. After hours flexibility may be needed to meet the need of patients and the department.
- Recognizes and performs duties which need to be performed although not directly assigned.
- Performs other duties as assigned.
PI274420694
