Job Description

Squirrel Hill Health Center (SHHC), is a Federally Qualified Health Center (FQHC), seeking a Prior Authorization Specialist. Prior Authorization Specialist ensures that healthcare services, medications, or treatments are approved by insurance providers before they are administered. Acting as a liaison between patients, healthcare providers, and insurance companies, this role streamlines the authorization process. The Specialist will assist SHHC Providers in managing and maintaining electronic or paper-based forms to ensure accurate and complete data collection and documentation. They will be prompt, courteous, professional, and accurate in interactions with SHHC patients, ensuring the smooth flow of both people and information through the SHHC system. The Specialist will work in cooperation with all members of the SHHC Team to provide the highest quality of patient care.

Responsibilities:

1. Authorization Management
   • Submit and follow up on prior authorization requests for medications, procedures, or treatments.
   • Communicate with insurance companies to ensure timely processing of authorizations.
   • Verify patients' insurance coverage and benefits for specific services.
2. Coordination
   • Collaborate with healthcare providers to gather necessary documentation and clinical information.
   • Act as a liaison between patients, healthcare providers, and insurance companies.
   • Notify providers and patients of approval or denial statuses, including next steps for appeals if necessary.
3. Documentation
   • Accurately document all communication, actions, and decisions related to prior authorizations and Provider forms distribution in the EMR..
   • Maintain compliance with HIPAA and other healthcare regulations.
4. Problem Resolution
   • Resolve authorization delays or denials by communicating with insurance representatives.
   • Analyze denial reasons and recommend appropriate follow-up actions.
5. Customer Service
   • Provide clear and empathetic communication to patients regarding insurance requirements.
   • Educate providers and staff about payer requirements and updates.
   • Act as a liaison between patients, physicians/NPs/PAs, and other entities regarding Clinical Operations and patient needs.
   • Obtain release of information to seek necessary records and ensure proper review and follow-up with physicians/NPs/PAs.
6. Compliance
   • Ensure forms comply with company, industry, or regulatory standards.
   • Accurately, promptly, and consistently document all patient interactions in the Electronic Health Record.
   • Maintain confidentiality and compliance with HIPAA.
7. Coordination of Services
   • Refer patients to the Care Navigation Team for necessary social services.
   • Coordinate clinics and other offsite prevention services at the direction of SHHC Management.
8. Other Duties
   • Perform other duties as directed.

Qualifications:

1. High school diploma or GED required; associate’s degree or healthcare-related certification preferred.
2. 1-3 years of experience in a healthcare setting, insurance verification, or prior authorization.
3. Knowledge of medical terminology, ICD-10, and CPT coding.
4. Proficiency in using healthcare software systems and ability to learn new systems.
5. Strong computer skills, including EHR, Microsoft Word, Teams, Outlook, and Excel.
6. Ability to assess, understand, and react effectively to the unique needs of various patient populations.
7. Excellent critical thinking, organizational, interpersonal, and communication skills.
8. Attention to detail for design accuracy and compliance.
9. Professional and effective communication skills with a wide range of clients in person and by telephone or Portal.
10. Courteous and respectful response to patient, clinician, and other requests.
11. Ability to manage time systematically and work efficiently and consistently.
12. Fluency in a second language is preferred.
13. Ability to work in any SHHC location onsite or remotely as needed.
14. Flexibility to accommodate occasional schedule changes to provide patient care.
15. CPR certification preferred but not necessary.
16. Commitment to serving populations consistent with SHHC’s mission.
17. All CDC recommended vaccinations, including annual Covid and Flu, required.

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