Job Description

Join to apply for the Prior Authorization Specialist role at Southern West Virginia Health System Job Statement/Summary Under the general administrative direction of a Regional Nurse Manager, the Prior Authorization Specialist is responsible for managing the process of obtaining insurance approval for medical services, treatments, and prescriptions before they are provided to patients. This involves interacting with insurance companies, healthcare providers, and patients to ensure all necessary documentation is submitted correctly and in a timely manner. The role requires a keen understanding of medical insurance processes, the ability to navigate complex healthcare systems, and excellent communication skills to handle both administrative and clinical tasks. ESSENTIAL FUNCTIONS & RESPONSIBILITIES OF THE POSITION Collaborate with physicians, healthcare providers, and insurance companies to gather necessary clinical information for authorization. Ensure that all required documentation is submitted accurately and in a timely manner to support authorization requests. Communicate authorization decisions, approval status, or denials to healthcare providers and patients. Follow up on pending or delayed prior authorization requests, identifying and addressing any barriers to obtaining timely approvals. Maintain accurate records of all prior authorization activities, ensuring compliance with legal and organizational standards. Stay updated on insurance policies, medical guidelines, and changes in prior authorization processes. Assist in appeals for denied authorizations by providing clinical documentation and support as needed. Educate patients and staff on the prior authorization process, requirements, and timelines. Participate in departmental meetings and provide input for process improvements related to prior authorizations. Demonstrates flexibility and willingness to cover shifts as needed to support staffing needs, ensuring uninterrupted patient care and team collaboration. Assists in providing adequate coverage for patient care in the event of staff shortages, maintaining high standards of care in all assigned areas. Continuously upholds nursing competencies and ensures compliance with all licensure requirements, including ongoing education and certification as mandated by regulatory bodies. The Prior Authorization Specialists may be required to travel to areas within West Virginia and occasionally elsewhere within the United States. This is not an all-inclusive job description; therefore, management has the right to assign or reassign schedules, duties, and responsibilities to this job at any time.

JOB REQUIREMENTS AND PREFERRED QUALIFICATIONS

Competencies Basic keyboarding and PC skills, Windows skills including WORD and Excel Use of printers, copiers and fax equipment Proficiency in electronic health records (EHR) systems. Strong critical thinking and problemsolving skills. Strong medical documentation skills. Demonstrates professionalism in all interactions with patients, families, colleagues, and external healthcare organizations Strong understanding of insurance processes, medical necessity guidelines, and clinical terminology. Strong attention to detail and accuracy Ability to work independently and manage multiple priorities. Ability to maintain confidentiality and adhere to HIPAA regulations. Education (level and type) and Related Work Experience Certified Medical Assistant or LPN Minimum of 3 years clinical/nursing experience, experience in prior authorizations preferred. LPNcurrent WV state license #J-18808-Ljbffr Southern West Virginia Health System

Job Tags

Work experience placement, Shift work,

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