Position Summary: This position is the frequently the first contact a patient has with the HMC system. A Hospital Prior Authorization Representative assesses patient medical records, prepares and submits authorization requests, and liaises with insurance companies to resolve issues. They also inform patients about request statuses, maintain detailed records, ensure compliance, collaborate with healthcare staff, address issues, and generate reports on authorization activities. Correctly identifies the patient, matches medical records, and facilitates hospital care, collect all required information necessary to meet state/federal regulations and to satisfy HMC billing processing requirements, including insurance coverage. This position requires excellent customer services skills and an ability to be able to explain to people what information is necessary and the rationale.
Position Details:
- Collection of demographic information using Meditech (Electronic Medical Record)
- Collect basic personal information from patient including age, race, ethnicities
- Collect addresses, phone numbers and other contact information
- Collect next of kin information
- Collect insurance/coverage information. Be able to discern what information is required based on type of insurance, i.e., on the job injury, motor vehicle accident, etc.
- Sequence the insurance in the correct order according to guidelines
- Based on specific criteria, request additional information, i.e. MSPQ/COB
- Verification of insurance coverage using AccuReg
- Review feedback from AccuReg for any issues related to non-coverage or data accuracy
- Review with the patient any feedback and reconcile accordingly
- Ability to decipher the appropriate action based on AccuReg feedback, i.e., change the information in Meditech or enter a dispute so a more senior person can review
- Verify insurance prior to the call
- Completion of Prior Authorization
- Assessing patient medical records and documentation to determine the necessity of procedures and treatments.
- Completing all the required fields and making accurate and complete notes to assist the HMC colleague who completes registration on site
- Preparing and submitting prior authorization requests to insurance companies for approval.
- Liaising with insurance companies to follow up on pending authorizations and resolve any issues or discrepancies.
- Informing patients about the status of their authorization requests and explaining any delays or denials.
- Keeping detailed records of all authorization requests, approvals, denials, and communications with insurance providers.
- Ensuring all authorization processes comply with hospital policies, insurance guidelines, and regulatory requirements.
- Working closely with healthcare providers, billing departments, and other hospital staff to ensure smooth and efficient authorization processes.
- Addressing and resolving any issues that arise during the authorization process, including appeals for denied requests.
- Generating reports on authorization activities, including approval rates, turnaround times, and any trends or issues identified.
Qualifications:
Required
- High school diploma or equivalent is required.
Preferred
- Two to three years of working in healthcare office setting
- Accuracy and attention to detail. Proactive approach to problem-solving and process improvement.
- Strong verbal and written communication skills, good organizational skills, efficient in computer operations including Microsoft Word, Excel, and Teams.
- Professional and courteous demeanor, excellent office and phone etiquette.
- Coding Certificate
Patient Interaction: Continuous
HIPAA: This position will have access to the following Protected Health Information in order to perform the duties related to their position at Hays Medical Center based on the following criteria:
- Primary – required (routine) to do the job
- Patient demographics
- Insurance/Coverage information:
- Scheduled service/provider
- Secondary - occasionally necessary to perform the job
- None- no approved access
- Clinical information beyond type of service
- Coding
Description of Information
Primary:
Patient Demographic Information (information used to identify a person): Name, Date of Birth, Address, Race, Marital Status, Religion
Secondary:
Clinical Information (information that describes a patient’s health status): Diagnosis, Reports/Medical Notes, Test Results, Problem List, Procedures, History and Physical
Coding Information (clinical information that is in (alpha) numeric format): ICD-9 Codes, Rev Codes, CPT Codes
Financial Information/Insurance (information related to insurance, billing and payment): Billing Information, Payer Name, Payer ID, Account Balances, Plan Elements Covered, Payment Information, Payment Rates
HaysMed is an Equal Opportunity Employer.
Req. 2231
