Job Description

Purpose:
Do you have experience with claims and authorizations?  Are you looking to grow your career?  UPMC is hiring a full-time Authorization Specialist to support its Revenue Cycle Behavioral Health department.  This role would work Monday through Friday from 8:30am until 5:00pm.  This position may be eligible to work a hybrid arrangement after training and at the manager’s discretion.

The Authorization Specialist performs authorization activities of inpatient, outpatient, and emergency department patients, as well as denial management and all revenue functions.  This employee will be handling authorizations for multiple outpatient behavioral health locations.  They need to demonstrate, through actions, a consistent performance standard of excellence to which all work is to conform.  The expertise of the Authorization Specialist includes working knowledge in the area of authorization related activities, including pre-authorizations, notifications, edits, denials, etc.  The Authorization Specialist demonstrates the philosophy and core values of UPMC in the performance of duties.

If you are ready to expand your healthcare experience, this could be the job for you!  Submit your application today.

Responsibilities:

General responsibilities:

• Maintain compliance with departmental quality standards and productivity measures.
• Work 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.
• Utilize 18+ UPMC systems and insurance payors or contracted provider web sites to perform prior authorization, edit, and denial services.
• Utilize authorization resources along with any other applicable reference material to obtain accurate prior authorization.

Prior authorization responsibilities:

• Review and interpret 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.
• Utilize 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.
• Ensure accurate coding of the diagnosis, procedure, and services being rendered using ICD-9-CM, CPT, and HCPCS Level II.
• Provide referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive nonclinical administrative time required of providers.
• Submit pertinent demographic and supporting clinical data to payor to request approval for services being rendered.

Retrospective authorization responsibilities

• Resolve basic authorization edits to ensure timely claim filing and elimination of payor rejections and or denials.

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