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The Authorization Specialist will perform authorization activities of inpatient, outpatient, and emergency department patients, denial management, and all revenue functions. Need to demonstrate, through actions, a consistent performance standard of excellence to which all work is to conform. The expertise of the Authorization Specialist shall include working knowledge in the area of authorization-related activities including pre-authorizations, notifications, edits, denials, etc. Above average working knowledge of Word and Excel.

Responsibilities:

• Reviews and interprets medical record documentation for patient history, diagnosis, and previous treatment plans to pre-authorize insurance plan-determined procedures to avoid financial penalties to patient, provider, and facility.

• Utilizes payor-specific approved criteria or state laws and regulations to determine medical necessity or the clinical appropriateness for inpatient admissions, outpatient facility, office services, durable medical equipment, and drugs in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease.

• Ensures accurate coding of the diagnosis, procedure, and services rendered using ICD-9-CM, CPT, and HCPCS Level II.

• Provides timely referral/pre-notification/authorization services to avoid unnecessary delays in treatment and reduce excessive nonclinical administrative time required of providers.

• Submits pertinent demographic and supporting clinical data to the payor to request approval for services being rendered.

• Maintains compliance with departmental quality standards and productivity measures.

• Works collaboratively with internal and external contacts specifically, Physician Services and Hospital Division, across UPMC as well as payors to enhance customer satisfaction and process compliance, ensuring the seamless coordination of work and avoiding a negative financial impact.

• Utilizes 18+ UPMC systems and insurance payor or contracted provider websites to perform prior authorization, edit, and denial services.

• Utilize authorization resources along with any other applicable reference material to obtain accurate prior authorization.

• Resolves basic authorization edits to ensure timely claim filing and elimination of payor rejections and or denials.

High School diploma or equivalent with 2 years working experience in a medical environment (such as a hospital, doctor's office, or ambulatory clinic) OR an Associate's degree and 1 year of experience in a medical environment required. (Bachelor's degree (B.A) preferred)

Completion of a medical terminology course (or equivalent) required

• Knowledge and interpretation of medical terminology, ICD-9, and CPT codes.

• Proficient in Microsoft Office applications

• Excellent communication and interpersonal skills.

• Ability to analyze data and use independent judgment. Understanding of authorization processes, insurance guidelines, third-party payors, and reimbursement practices

• Experience utilizing a web-based computerized system. Licensure, Certifications, and Clearances:

• Act 31 Child Abuse Reporting with renewal

• Act 33 with renewal

• Act 34 with renewal

• Act 73 FBI Clearance with renewal

UPMC is an Equal Opportunity Employer/Disability/Veteran