Altru Health System

Non-Clinical Pre-Authorization

Grand Forks, ND
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Sep 30, 2020
Job Type
Job Summary

Under the general direction of the Pre-Service Manager and supervisor, the Non-Clinical Pre-Authorization Representative is responsible for Insurance verification, pre-payments, estimates, pre-authorization, prior authorizations, referral management, and contacting insurance organizations to obtain pre-and prior authorization for referred services/procedures. The Non-Clinical Pre-Authorization Representative will also review referrals and correspondence and communicate with providers and members regarding final referral determination and will also aid members/providers through the appeal process.

Essential Job Functions

Performs pre-authorization and prior authorization for contracted Managed Care programs. Review structured clinical data matching it against specified medical terms and diagnoses or procedure codes (without the need for interpretation) and follow established procedures for authorizing request or referring request for further review. Corresponds with members and providers regarding final pre and prior authorization, coverage limitations, precertification numbers as needed, denial letters regarding disapproved referrals/follow ups, and appeal process assistance. Also, files complete precertification requests as per established procedures.

Investigates and resolves incoming calls and visits from members and providers with questions or concerns about referral management while also providing referral management education to members and providers regarding medical benefits, referral status and prior authorizations. Assists third party payors in the investigation and resolution of member concerns/complaints regarding referral determinations while demonstrating knowledge of contracted referral agreements between Altru Health System and the providers within our network.

Reviews referrals and correspondence with the Medical Director and obtains additional medical information for referral determinations from providers/members. Works with Pre-Authorization, Business Office, and Utilization Management regarding referred services and enters/updates all referral information per standard operating procedure. Coordinates external referrals with members, primary care providers, specialty physicians and tertiary care centers.

Contacts insurance organizations to obtain pre and prior authorization for referred services/procedures, gathers medical information to establish medical necessity/appropriateness and relays this information to insurance organizations.

Reviews claims for medical necessity and appropriateness and approves claims or refers for Medical Director review.

Demonstrates knowledge of the Managed Care Information Systems programs for pre-and prior authorization and eligibility purposes, knowledge of state/federal benefits, coverage mandates and related process requirements.

Performs other duties as assigned or needed to meet the needs of the department/organization.

Demonstrates understanding and follows infection control policies and procedures according to standard operating procedure.

Maintains requirements for age specific competencies for the position and demonstrates the knowledge or principles of growth and developments and the skills necessary to provide patient/customer care/services.

Education & Experience

A minimum of 2 years of related experience-Preferred

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