Authorization Specialist - Pediatrics - Children's Hospital

UPMC is hiring a full-time Authorization Specialist to join their Pediatric Endocrinology team at UPMC Children's Hospital! The Pediatric Endocrinology department is a large division with approximately 40 providers. This position will be working with our patients and families with diabetes doing authorizations for life saving medications. This is also in part a front facing position with some direct patient care.

As the Authorization Specialist, you will perform authorizations for medication and diabetes medical devices, scheduling appointments for classes and management visits run by the diabetes educators, performing clerical work for classes or inpatient education, and you will work closely with diabetes educators, dietitians, and providers.

Hours for this position will be Monday through Friday, 8:00am to 4:30pm, with no evenings, weekends, or holidays! Previous authorization experience is preferred, but not required.

Responsibilities:

• Prior authorization responsibilities1. 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. 2. 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. 3. Ensures accurate coding of the diagnosis, procedure, and services being rendered using ICD-9-CM, CPT, and HCPCS Level II. 4. Provides referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive nonclinical administrative time required of providers. 5. Submits pertinent demographic and supporting clinical data to payor to request approval for services being rendered.
• General responsibilities:1. Maintains compliance with departmental quality standards and productivity measures. 2. 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.3. Utilizes 18+ UPMC system and insurance payor or contracted provider web sites to perform prior authorization, edit, and denial services.4. Utilize authorization resources along with any other applicable reference material to obtain accurate prior authorization.
• Retrospective authorization responsibilities1. 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 31 Child Abuse Reporting with renewal
• Act 33 with renewal
• Act 34 with renewal
• Act 73 FBI Clearance with renewal

UPMC is an Equal Opportunity Employer/Disability/Veteran

UPMC has a Center for Engagement and Inclusions that is charged with executing leading-edge and next- generation diversity strategies to advance the organization's diversity management capability and its national presence as a diversity leader. This includes having Employee Resources Groups, such as PRIDE Health or UPMC ENABLED (Empowering Abilities and Leveraging Difference) Network, that support the implementation of our diversity strategy.

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