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Non-Clinical Pre-Authorization

Employer
Altru Health System
Location
Grand Forks, ND
Salary
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Job Details

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.

•Demonstrates knowledge and understanding of and compliance with: •All pertinent safety, health and environmental policies, procedures and guidelines.

•Working safely, without causing harm or risk to self, others or property.

•The work environment safety procedures and prompt reporting of unsafe practices, procedures, accidents, injuries or other safety violations to the Leader.

•The use of all safety equipment and personal protective equipment

Education & Experience

Degree/Diploma

Experience

Preferred

A minimum of 2 years of related experience

Company

Do what you love. Make a difference. Join our team of over 4,000 health professionals and support staff committed to caring for the region for more than 100 years.

At Altru Health System, we are serious about providing an exceptional patient experience and positively impacting the communities we serve. Our physician-led, community-owned, not-for-profit health system serves over 225,000 residents in northeast North Dakota and northwest Minnesota. We are a proud member of the Mayo Clinic Care Network.

If reasonable accommodation is needed to apply or interview for a position, please contact careers@altru.org or 701.780.5123.

Company info
Website
Telephone
701-780-5123
Location
Grand Forks
North Dakota
US

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