Prior Authorization Rep Sr

Hennepin Healthcare is an integrated system of care that includes HCMC, a nationally recognized Level I Adult Trauma Center and Level I Pediatric Trauma Center and acute care hospital, as well as a clinic system with primary care clinics located in Minneapolis and across Hennepin County. The comprehensive healthcare system includes a 473-bed academic medical center, a large outpatient Clinic & Specialty Center, and a network of clinics in the North Loop, Whittier, and East Lake Street neighborhoods of Minneapolis, and in the suburban communities of Brooklyn Park, Golden Valley, Richfield, and St. Anthony Village. Hennepin Healthcare has a large psychiatric program, home care, and operates a research institute, philanthropic foundation, and Hennepin EMS. The system is operated by Hennepin Healthcare System, Inc., a subsidiary corporation of Hennepin County. 

Equal Employment Opportunities: We believe equity is essential for optimal health outcomes and are committed to achieve optimal health for all by actively eliminating barriers due to racism, poverty, gender identity, and other determinants of health. We are committed to equitable care and working in an environment that celebrates, promotes, and protects diversity, equity, inclusion, and belonging. We are committed to bringing in individuals with new cultural perspectives to assist in creating a more equitable healthcare organization.

JOB DETAILS
Department: Financial Securing
FTE: 1.00 (80 hours per pay period)
Workdays: Monday - Friday
Shift(s): Days
Shift Length: 8 hours
Location: Remote*

*Current List of non-MN States where Hennepin Healthcare is an Eligible Employer: Alabama, Arizona, Arkansas, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Mississippi, Nevada, North Carolina, North Dakota, New Mexico, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin.

Purpose of this position: The Prior Authorization Specialist plays a key role in the patient financial experience by coordinating pre-authorizations for patients and often handling cases that need quick turnaround (e.g., last-minute scheduled services). The individual in this role is an expert on payer regulations and contracts, and they serve as a point of contact for peers looking to resolve questions or issues regarding prior authorizations

RESPONSIBILITIES

• Utilizes online systems, phone communication, and other resources to secure prior authorizations within a timeframe before scheduled appointments/procedures/same day surgeries and during or after care for unscheduled patients
• Verifies medical necessity in accordance with the Centers for Medicare & Medicaid Services (CMS) standards and communicates relevant coverage/eligibility information to the provider/patient, as it pertains to prior authorization
• Coordinates benefits by effectively determining primary, secondary, and tertiary liability when needed
• Obtains pre-certifications and prior authorizations from third-party payers in accordance with payer requirements
• Alerts physician offices to issues with verifying insurance and/or obtaining prior authorizations
• Demonstrates expert understanding of insurance terminology (e.g., co-payments, deductibles, allowances, etc.), and analyzes information received to determine patients’ out-of-pocket liabilities, based on prior authorization status
• Follows up on all prior authorization submissions for timely response
• Follows up on any prior authorization denials; assists Utilization Management with appeals, as needed
• Connects patients with financial counselors, as necessary
• Maintains productivity and quality standards and assists other team me