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Pre-Authorization Analyst

Pre-Authorization Analyst

Requisition ID 
2017-5152
# of Openings 
1
Address 
100 Front Street
Job Locations 
US-MA-Worcester
Posted Date 
12/7/2017
Category 
Administrative - Clinical
Department 
REV OPS BUSINESS OFFICE
Job Code 
AO14

More information about this job

Overview

 Reliant Medical Group is seeking an experienced Preauthorization Analyst to join our exciting and innovative team. If you are looking for a career that will transform, inspire, challenge and reward you then come join us! 

 

Full Time: 38.75 hours per week

Monday - Friday

8:30am-5:00pm

 

The Preauthorization Analyst processes authorizations, redirections and denials for the organization members using established protocols, policies and procedures and related duties.

Responsibilities

  • Processes authorizations, redirections and denials for the organization, screens for member eligibility, retrieve clinical notes from external providers to complete our electronic medical record, and accurately enters information into the computer system. Processes authorizations, redirections, and denials per specific payor’s guidelines. 
  • Approves, redirects, and denies routine Fallon Health, Tufts Commercial, Tufts Medicare Preferred, Blue Cross Blue Shield, Harvard Pilgrim requests by applying each physician determined protocols, policies and procedures; requests not meeting protocol parameters are prepared for physician review. Ensures that all pertinent information accompanies requests for further review; pending case to each payor’s pre-authorization department or RMG Medical Director, according to the insurance plan. 
  • Performs data entry and research on all referral requests to include inpatient surgeries, same day surgeries, specialist and PCP referrals, care management, SNF, VNA, Medicare part B services, and track inpatient admissions using payor reports.
  • Works closely with appropriate clinic and payor contacts to complete the referral process.  Monitor and research Tufts Medicare Preferred electronic claim report to determine if claims should be paid or not, working closely with RMG’s Medical Director.
  • Communicates with internal and external providers, staff, patients and payor representatives to facilitate the pre-authorization, redirection, or denial process. Provides recommendations to PCPs whether to approve, redirect, or deny patients based on a detailed research.
  • Works in conjunction with the Provider Relations Representatives or others to conduct orientations, updates and educational sessions for providers and staff, as requested.
  • Gathers all pertinent information for each referral to determine appropriateness, accuracy, contractual status, codes and to follow through to fruition (approval, redirection, and denial).
  • Serves as a resource for the organization’s providers, staff, and patients. 
  • Has a clear understanding and complies with risk-based contracts as this position is directly related to the financial health of the organization.

Qualifications

  • High School diploma and one to three years of related work experience. 
  • Knowledge of
  • Medical terminology and managed care.
  • Excellent communication, organizational and interpersonal skills.
  • Ability to work independently and be comfortable talking with providers, staff, patients, and outside organizations.
  • Strong ability to multi-task and cover for others within the department during absences.
  • Knowledge of various software applications such as Microsoft Word, Excel, Outlook, etc.

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