• Review and process prior authorization request for medications in the client's clinics.
• Verify insurance coverage and ensure all necessary documentation is completed.
• Communicate with medical staff, insurance companies, and specialty pharmacies regarding authorization status.
• Maintain accurate records of authorizations and follow-up as needed.
• Collaborate with medical staff to ensure compliance with policies and procedures.
• Observe and understand prescribing trends within ambulatory clinics.
• Ensure patients receive the services that require prior authorization from insurance carriers by addressing and rectifying rejected claims that require additional documentation and/or Peer to Peer Consultation.
• Assist in resolving any authorization related issues or denials.
• Maintains an audit trail of changes to authorization requirements to assist with root cause analysis and support cause of appeals.
• Analyzes the prior authorization denial report to identify reasons for denials and recommends workflow adjustments as needed, collaborating with affected departments on any workflow or system build issues.
• Maintains a current knowledge related to insurance changes and requirements for prior authorization.
• Improve patient service experience.
• Attends and participates in meetings, as needed.
• Performs other duties as assigned by the Director of Pre-Patient Access.

Minimum Qualifications

• Licensed as a medical professional in the state of Illinois with two (2) years of experience of prior authorization experience/utilization management

• Bachelor’s degree from an accredited college or university with one (1) year of prior authorization experience/utilization management experience

• Two (2) years of relevant medication prior authorization experience
• One (1) year experience with electronic medical records (EMR)
• Prior experience working in a physician group, insurance company or management services organization

Preferred Qualifications

• Bachelor’s degree in nursing, Health Science, Business or related field from an accredited college or university
• Experience in claims adjudication experience
• Care management or medical insurance experience
• Prior experience using InterQual or Milliman criteria sets

Knowledge, Skills, Abilities and Other Characteristics

• Excellent verbal, written communication, and interpersonal skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
• Knowledge and proficiency with Microsoft applications and internet-based programs
• Strong interpersonal skills with the ability to establish strong working relationships
• Strong time management skills to prioritize assignments and meet the designated deadlines
• Ability to anticipate, recognize, and meet the needs of patients and families
• Ability to work in a team-based environment to accomplish goals and objectives
• Ability to demonstrate respect and sensitivity for cultural diversity in CCH work force and patient population
• Ability to critically think, problem solve and make independent decisions supporting the authorization process, including interactions with payer representative, physicians, and hospital case managers