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SUMMARY

This position is responsible for exercising independent judgment to process referrals and prior authorizations administration. All referrals and prior authorizations will be processed according to the appropriate insurance. This position is responsible for both on- and off-site services for multiple providers including Primary care, Specialty providers, Dental, Therapies including Physical, Occupational, Speech Therapy and Audiology.

ESSENTIAL FUNCTIONS

+ Appropriately prioritize all prior authorization request/ referrals. Submits for onsite and offsite appointments, outpatient procedures, diagnostics procedures and/ or therapies

+ Reviews future appointments in NextGen on a daily and weekly basis to verify that all required authorizations have been requested, paying close attention to short notice and same day appointments

+ Reviews patient information including diagnosis ICD10 codes, CPT codes and submits authorization request and all required documentation to the appropriate insurance companies

+ Track pending authorizations, follow up on submitted authorizations

+ Processes approved/denied requests with accuracy and meeting timely standards to include data-entry, coordination with offsite providers and clinical staff for scheduling and communication of status and requests

+ Performs other duties as required and assigned

KNOWLEDGE, SKILLS AND ABILITIES

+ Knowledge of AHCCCS, CRS, and private insurance guidelines

+ Knowledge of precertification, referrals, and prior authorization

+ Knowledge of medical terminology, CPT, and ICD-10 codes and practices

+ Skill and proficiency in using Microsoft Office Suite

+ Ability to maintain confidentiality of patient, personnel, and corporate data

+ Ability to cross reference data to assure accuracy and completeness

+ Ability to post information to electronic records and maintains the electronic file and any manual files

+ Ability to effectively manage time with a proven ability to meet deadlines; organization and attention to detail

+ Competent using a Practice Management System

+ Ability to communicate effectively, both verbally and in writing with patients, their families and all levels of personnel. Demonstrates tact and understanding when dealing with patients, families, and staff

+ Ability to maintain confidentiality of patient data according to HIPAA regulations

+ Ability to operate personal computer and related office equipment as needed to perform job functions

Qualifications

Education:

High School diploma or general education degree (GED) required

Experience:

At least one year in related field and/or experience in a healthcare environment preferred

Licenses and Certificates:

None required

AGE OF PATIENTS ATTENDED BY EMPLOYEE IN THIS POSITION

Check all that apply:

_X_ N/A ___ Neonatal (newborn) ___ Pediatric (birth-13) ___ Young Adult (14-21) ___ Adult (21-65)

FINGERPRINT CLEARANCE

Employees are required to maintain a current Arizona Department of Public Safety Level 1 Fingerprint Clearance Card. Evidence of a current and valid fingerprint clearance card must be received to begin and maintain employment.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

The physical demands and work environment described here are representative of that which an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee is occasionally required to sit; climb or balance; stoop, kneel, crouch, or crawl; and taste or smell. The employee must frequently lift and/or move up to 25 pounds and occasionally lift and/or move more than 100 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

While performing the duties of this job, the employee is frequently exposed to toxic or caustic chemicals. The employee is occasionally exposed to fumes or airborne particles, risk of electrical shock, and risk of radiation. While performing the duties of this job, the employee may potentially be exposed to infectious organisms during routine and emergency situations. The noise level in the work environment is usually moderate.

BLOODBORNE PATHOGEN CATEGORY: 3

Category 1: Performs tasks that involve exposure to blood, body fluids or tissue. Use of appropriate protective measures should be required.

Category 2: Performs tasks that involve no exposure to blood, body fluids or tissue but employment may require performing unplanned Category 1 tasks. The normal work routine involves no exposure to blood, body fluids or tissue but exposure or potential exposure may be required as a condition of employment. Appropriate protective measure should be readily available.

Category 3: Performs tasks that involve no exposure to blood, body fluids or tissue and Category 1 tasks are not a condition of employment. The normal work routine involves no exposure to blood, body fluid or tissues.