Non Clinical Pre Authorization

Non-Clinical Pre-Authorization Representative

Everything we do is underscored by a why and that why is one another.

Location : Altru Health System PO Box 6002 Grand Forks, ND 58201 Pay Range : $17.07 - $25.60

Summary : Under the general direction of the Pre-Service Manager and supervisor, the Non-Clinical Pre-Authorization Representative is responsible for insurance verification, pre-payments, estimates, pre-authorization, prior authorizations, referral management, and contacting insurance organizations to obtain pre-and prior authorization for referred services / procedures. The Non-Clinical Pre-Authorization Representative will also review referrals and correspondence and communicate with providers and members regarding final referral determination and will also aid members / providers through the appeal process.

Essential Job Functions :

• Performs pre-authorization and prior authorization for contracted Managed Care programs. Reviews structured clinical data matching it against specified medical terms and diagnoses or procedure codes (without the need for interpretation) and follow established procedures for authorizing request or referring request for further review. Corresponds with members and providers regarding final pre and prior authorization, coverage limitations, precertification numbers as needed, denial letters regarding disapproved referrals / follow ups, and appeal process assistance. Also, files complete precertification requests as per established procedures.
• Investigates and resolves incoming calls and visits from members and providers with questions or concerns about referral management while also providing referral management education to members and providers regarding medical benefits, referral status and prior authorizations. Assists third party payors in the investigation and resolution of member concerns / complaints regarding referral determinations while demonstrating knowledge of contracted referral agreements between Altru Health System and the providers within our network.
• Reviews referrals and correspondence with the Medical Director and obtains additional medical information for referral determinations from providers / members. Works with Pre-Authorization, Business Office, and Utilization Management regarding referred services and enters / updates all referral information per standard operating procedure. Coordinates external referrals with members, primary care providers, specialty physicians and tertiary care centers.
• Contacts insurance organizations to obtain pre and prior authorization for referred services / procedures, gathers medical information to establish medical necessity / appropriateness and relays this information to insurance organizations.
• Reviews claims for medical necessity and appropriateness and approves claims or refers for Medical Director review.
• Demonstrates knowledge of the Managed Care Information Systems programs for pre-and prior authorization and eligibility purposes, knowledge of state / federal benefits, coverage mandates and related process requirements.
• Performs other duties as assigned or needed to meet the needs of the department / organization.

Work Experience : Preferred : A minimum of 2 years Related Experience

Language Requirements : This position requires proficiency in reading, writing, and speaking English to ensure effective communication in the workplace and with patients, families, and team members.

Physical Demands :

Weight Demands :

Working Conditions :

Driving Requirement Definitions :

Driving Requirement for this position : Infrequent Driver Reference ID : R6679

Making a real difference. For one another.

To take the best care of our patients and community including friends, family, and neighbors we need people who are committed to growth, excellence, and one another.

At Altru, you'll find a culture where support and teamwork are at the heart of what we do. You'll have opportunities to advance your skills, work with the latest technologies, experience the fulfillment that comes from giving back, and take your career wherever you want it to go.

Join our team and be a part of a small community with a big heart.

Altru offers a comprehensive benefits package to its full- and part-time employees. Excellent benefits include a health plan and 401(k) retirement plan. Other benefits include a dental plan, vision plan, life and disability insurance, education assistance, paid time off (PTO)