UPMC Department of Pediatrics is hiring a full-time Authorization Specialist to join their Genetic and Genomic Medicine team out of Children's Hospital. This is a Monday through Friday daylight position with no evenings or weekends. This role will primarily be responsible for obtaining authorizations for genetic testing, appointment authorizations, medication authorizations, scheduling, and other office work as assigned.
The Division of Genetic and Genomic Medicine is a highly collaborative, mission-driven department that supports specialized pediatric genetics services across a growing clinical division. This position offers the opportunity to work closely with an experienced interdisciplinary team, contribute to meaningful patient care operations, and help support process improvement within a specialized and evolving area of medicine.
Purpose:
To 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.The Authorization Specialist shall demonstrate the philosophy and core values of UPMC in the performance of duties.
Responsibilities:
- Prior authorization responsibilities1. 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. 2. 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. 3. Ensures accurate coding of the diagnosis, procedure, and services being rendered using ICD-9-CM, CPT, and HCPCS Level II. 4. Provides referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive nonclinical administrative time required of providers. 5. Submits pertinent demographic and supporting clinical data to payor to request approval for services being rendered.
- General responsibilities:1. Maintains compliance with departmental quality standards and productivity measures. 2. 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 to avoid a negative financial impact.3. Utilizes 18+ UPMC system and insurance payor or contracted provider web sites to perform prior authorization, edit, and denial services.4. Utilize authorization resources along with any other applicable reference material to obtain accurate prior authorization.
- Retrospective authorization responsibilities1. Resolves basic authorization edits to ensure timely claim filing and elimination of payor rejections and or denials.
Purpose:
To 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.The Authorization Specialist shall demonstrate the philosophy and core values of UPMC in the performance of duties.
Responsibilities:
- Prior authorization responsibilities1. 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. 2. 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. 3. Ensures accurate coding of the diagnosis, procedure, and services being rendered using ICD-9-CM, CPT, and HCPCS Level II. 4. Provides referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive nonclinical administrative time required of providers. 5. Submits pertinent demographic and supporting clinical data to payor to request approval for services being rendered.
- General responsibilities:1. Maintains compliance with departmental quality standards and productivity measures. 2. 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 to avoid a negative financial impact.3. Utilizes 18+ UPMC system and insurance payor or contracted provider web sites to perform prior authorization, edit, and denial services.4. Utilize authorization resources along with any other applicable reference material to obtain accurate prior authorization.
- Retrospective authorization responsibilities1. Resolves basic authorization edits to ensure timely claim filing and elimination of payor rejections and or denials.
Qualifications
- 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
- Skills Required: Knowledge and interpretation of medical terminology, ICD-9, and CPT codes
- Must be proficient in Microsoft Office applications Excellent communication and interpersonal skills
- Ability to analyze data and use independent judgment
- Skills Preferred: Understanding of authorization processes, insurance guidelines, third party payors, and reimbursement practices
- Experience utilizing a web-based computerized system.
Licensure, Certifications, and Clearances:
*Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.
UPMC is an Equal Opportunity Employer/Disability/Veteran