Authorization Specialist (Children's Hospital of Pittsburgh)

Authorization Specialist

The Division of Pediatric Ophthalmology, Strabismus, and Adult Motility is hiring a full-time Authorization Specialist to support their team located at UPMC Children's Hospital of Pittsburgh : 4401 Penn Avenue, Pittsburgh, PA 15224. This role will work Monday through Friday 8am to 4 : 30pm (1 day work from home).

The primary responsibilities of this role include completing surgery authorizations, genetic Testing authorization, out of state authorizations, radiology authorizations (and other duties as assigned).

The Division of Pediatric Ophthalmology, Strabismus, and Adult Motility at UPMC Children's Hospital of Pittsburgh is comprised of 4 clinic locations and one administrative space, all working as a team to provide the highest level of care to patients and families through clinical expertise, research initiatives, and strong administrative support.

Responsibilities

1. Reviews and interprets medical record documentation for patient history, diagnosis, and previous treatment plans to pre-authorize insurance plan determined procedures to avoid financial penalties to patient, provider and facility. Utilizes payor-specific approved criteria or state laws and regulations to determine medical necessity or the clinical appropriateness for inpatient admissions, outpatient facility, office services, durable medical equipment, and drugs in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury, or disease. Ensures accurate coding of the diagnosis, procedure, and services being rendered using ICD-9-CM, CPT, and HCPCS Level II. Provides referral / pre-notification / authorization services timely to avoid unnecessary delays in treatment and reduce excessive nonclinical administrative time required of providers. Submits pertinent demographic and supporting clinical data to payor to request approval for services being rendered.

2. Maintains compliance with departmental quality standards and productivity measures. Works collaboratively with internal and external contacts specifically, Physician Services and Hospital Division, across UPMC as well as payors to enhance customer satisfaction and process compliance, ensuring the seamless coordination of work and to avoid a negative financial impact. Utilizes 18+ UPMC system and insurance payor or contracted provider web sites to perform prior authorization, edit, and denial services. Utilizes authorization resources along with any other applicable reference material to obtain accurate prior authorization.

3. Resolves basic authorization edits to ensure timely claim filing and elimination of payor rejections and / or denials.

Qualifications

High School diploma or equivalent with 2 years working experience in a medical environment (such as a hospital, doctor's office, or ambulatory clinic) OR an Associate's degree and 1 year of experience in a medical environment required. (Bachelor's degree (B.A) preferred). Completion of a medical terminology course (or equivalent) required.

Skills Required : Knowledge and interpretation of medical terminology, ICD-9, and CPT codes. Must be proficient in Microsoft Office applications. Excellent communication and interpersonal skills. Ability to analyze data and use independent judgment.

Skills Preferred : Understanding of authorization processes, insurance guidelines, third party payors, and reimbursement practices. Experience utilizing a web-based computerized system. Licensure, Certifications, and Clearances : Act 34.

UPMC is an Equal Opportunity Employer / Disability / Veteran