Process prior authorization request in accordance with standards for accuracy, timeliness, and productivity. Uses various business applications to perform analysis, obtain information, and enter prior authorization data necessary for claims adjudication.Utilizes reasoning skills to identify missing information and make prior authorization processing determinations based upon clinical protocols and client guidelines. Interacts with internal and external customers to provide and obtain information and ensures the delivery of outstanding service and quality.
- Verify insurance information with appropriate insurance carrier.
- Accurately process prior authorization request in accordance with insurance specifications.
- Consult with Providers regarding specific diagnosis information, as it relates to the referral.
- Send referral notification letters to patients which includes contact information related to scheduling their specialty appointment with the referred to specialist.
- Process between 35-40 referrals per day which includes: obtaining prior authorization if needed, verify that refer to provider accepts patients insurance, fax patient records to the refer to specialist and verify fax transmission, prepare and mail referral notification letter after verifying refer to Provider’s contact information, update information on the referral tracking log, follow-up to determine if appointment was kept.
- Provide weekly and as needed updates to Providers regarding referral status; answer questions regarding patient referral appointments.
- Provide and document referral follow up, i.e., appointment kept, missed appointment, etc., on referral tracking log and/or in Pearl Electronic Medical Records System.
- Answer telephone; respond to voicemail, email and Pearl mail.
- Prepare weekly/monthly departmental reports as needed and when requested.
- Refer patient referral requests to the appropriate Provider staff.
- Provide input for the development and/or revision of departmental policies.
- Maintain compliance with departmental and other MHSI policies and procedures.
- Attend seminars, training sessions, and meetings to keep abreast of the changes related to job duties and department.
- Safeguards confidentiality of the medical charts/records and complies with all local, state, and federal laws pertaining to medical records. Complies with all HIPAA and other privacy and security regulations.
- Participates as a team member with Medical Services staff, attending Medical Services meetings and continuing education in-services.
- Participates in organization-wide quality improvement initiatives as requested.
- Adheres to MHSI core values and customer service expectations.
- Assists in Medical Services department on an as needed basis.
- Perform other department related job duties, as may be assigned.
Computer literacy required (Windows operating systems – Microsoft Word, Excel). Able to demonstrate good oral and written communication skills.
Only those candidates with the experience, knowledge, skills and education listed above will be considered. If you do not possess these as listed above, please do not apply.
Milwaukee Health Services, Inc. is an equal opportunity employer.
Milwaukee Health Services, Inc. does not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or veteran status.