Prior Authorization Quality Analyst

Qualifications

• Must hold an active PHRN license (not a USRN license holder)
• Relevant experience as a Quality Auditor in Clinical Services within a healthcare BPO environment; alternatively, 4 to 7 years of specialized experience in Clinical Authorization or Utilization Review is preferred
• Strong familiarity with EPIC, MCG, or InterQual guidelines required
• Demonstrated job stability, with a consistent employment history and minimal transitions

Job Description

1. Audit

• Completing QA audits for their processes by following the QIP
• Providing feedback to team members on all errors
• Escalating any anomalies / trends / Compliance issues
• Performing the actual production work to keep abreast of the latest updates and practical scenarios
• Participating in client calls to capture process updates and monitoring compliance to the updates

1. Process

• Contact insurance carriers to verify patients insurance eligibility, benefits, and requirements.
• Request, track, and obtain pre-authorization from insurance carriers within time allotted for medical and services.
• Review, request, follow up and secure authorizations for high dollar cost oncology chemotherapy drugs.
• Demonstrate and apply knowledge of medical terminology, high proficiency of general medical office procedures including HIPAA regulations.
• Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed.
• Review denials and follow up with provider to obtain medically necessary information to submit an appeal of the denial.
• Prioritize the incoming authorizations by level of urgency to the patient.
• Manage correspondence with insurance companies, physicians, specialists, and patients as needed, including documenting in the EHR as appropriate.
• Respond to clinical questions regarding payer medical policy guidelines