NI-Specialist, Referral & Prior Authorization

J  o  b    D  e  s  c  r  i  p  t  i  o  n

JOB INFORMATION

Effective Date:

3/11/2018

Entity:

Illinois

Job Code:

NI-4342AC

Job Title:

NI-Specialist, Referral & Prior Authorization

Exemption Status:

Non-Exempt

JOB SUMMARY

The Referral and Prior Authorization Representative is responsible for insurance verification, determining prior authorization requirements, obtaining referrals for outpatient services and benefit counseling functions.  The position is accountable for multiple electronic work queues in performing their duties.  The incumbent works with internal and external customers, including patients, families, third party payers, clinical staff, and review organizations to accomplish their objectives.

This position represents UW Health and the Revenue Cycle team by adhering and upholding the UW Health iCare values and UW Health Service Excellence Standards of Behavior in providing the highest quality service to our customers. They will be friendly, knowledgeable, flexible, and reliable. They will listen to, anticipate, recognize, and satisfy our customer's needs. We will improve our Referral and Prior Authorization process while ensuring the highest level of satisfaction, keeping our promises and commitments, and demonstrating our commitment through respect, knowledge, responsiveness, and courtesy.    They will support their co-workers, engage in positive interactions, demonstrate friendliness by smiling and making eye contact when greeting all customers, provide helpful assistance in anticipating and responding to the needs of our customers and staying calm under pressure to deal effectively with difficult people.

MAJOR RESPONSIBILITIES

•

Contacts insurance companies to obtain benefit information and requirements related to pre-certification, pre-existing condition clauses, referral requirements.

•

Enters benefit and pre-certification information into Health Link.

•

Determines the appropriate payer plans and files orders to drive insurance proration’s and discounts to ensure accurate and timely reimbursement.

•

Contacts appropriate physician office or department so appointment scheduling may proceed.

•

Provides clinical documentation to insurance companies to support medical necessity of scheduled services.

•

Explains insurance benefits to patients.

•

Obtains a financial statement and financial responsibility form as necessary

•

Collects deductibles and prepayments as required.

•

Refers patients with limited insurance or high financial liability to a Financial Counselor, and refers patients to the Government Program Coordinator to determine if referral to alternate funding sources is appropriate.

•

Educates medical staff and other appropriate UW Health Health System personnel regarding prior authorization and referral processes.

•

Researches and appeals payment denials, as appropriate.

ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS.

X

Non-Clinical

JOB REQUIREMENTS

High School Diploma

or GED.

Preferred

2 years

experience in the healthcare or related field with emphasis on insurance prior authorization and referral processes.

Preferred

•

Must be detail oriented and accurate.

•

Excellent customer service, interpersonal and organizational skills.

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Ability to use good judgments in highly emotional and demanding situations.

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Ability to react to frequent changes in duties and volume of work.

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Excellent oral and written communication skills.

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Ability to listen empathetically.

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Ability to logically and accurately organize details.

•

Ability to manage multiple tasks with ease and efficiency.

•

Self-starter with a willingness to try new ideas.

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Ability to work independently with minimal supervision and be result oriented.

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Positive, can-do attitude coupled with a sense of urgency.

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Effective interpersonal skills, including the ability to promote teamwork.

•

Strong problem solving skills.

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Ability to ensure a high level of customer satisfaction including employees, patients, visitors, referring physicians and external stakeholders.

•

Excellent computer operating skills (keyboard, mouse).

•

Ability to use various computer applications including EPIC and MS Office.

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Basic math skills and knowledge of general accounting principles.

•

Maintains confidentiality of sensitive information.

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Broad knowledge of health care business office practices and principles.

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Knowledge of medical and insurance terminology, CPT, ICD coding structures.

•

Knowledge of Business Office policies and procedures.

•

Ability to type 35 words per minute preferred.

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

Standing

X

Walking

X

Climbing

X

Bending

X

Crouching

X

Pushing / Pulling

X

Carry

X

Fine Hand / Eye Coordination

X

Color Discrimination

X

Hearing Ability

X

Lifting / Lowering 1 -15 lbs.

X

15 - 30 lbs.

X

30 - 50 lbs.

X

Over 50 lbs.

UW Health does not require, nor does it expect that its employees lift more than 50 lbs unassisted. Objects in excess of 50 lbs should be lifted or moved with mechanical means or through a team lift. Employees in patient care areas are expected to utilize mechanical lifts and adhere to the "Use of Mechanical Lifts (Liko)" policy in the Patient Services Policy and Procedure Manual.

Concentration on Detail

X

Attention Span of 1 + Hours on a Task

X

Ability to Remember Multiple Tasks

X

Oral Communication

X

Written Communication

X

Exposure to Blood and Body Fluids

X

Exposure to Toxins, Cytotoxins, Poisons

X

Exposure to Extreme Heat, Cold, Temp Fluctuations

X

Exposure to Hazardous Chemicals

X

Exposure to Radiation

X

Other - Working with patients in crisis who may be volatile and potentially violent.

Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.