Pre Authorization Specialist at Cherokee Nation

Provides accurate and complete data input for pre-certification/pre-authorization requests. Provides excellent customer service for the benefit of the patient and Cherokee Nation. Supports the mission, vision, and philosophy of Cherokee Nation Health Services.

Possess knowledge of insurance, billing, and the authorization processes in order to initiate and verify insurance benefits. Assesses patient status, obtains authorization of hospitalization and some outpatient services prior to services rendered. Provides retro reviews and appeals to insurance companies as needed. Answers calls from insurance companies, physician offices, hospitals, and patients using exemplary customer service skills. Enters required information (non-clinical and structural clinical data) accurately into computer base. Documents pre-certification numbers as needed in Electronic Health Records (EHR) and files. Completes pre-certification requests per established procedures. Coordinates and works with providers, case management, insurance carriers, scheduling, patient benefit coordinators, and the patient in securing authorization(s)/payment(s) of service(s) provided. Maintains patient confidentiality as defined by state, federal, tribal, and any applicable regulations. Establishes effective rapport with other employees, professional support service staff, customers, clients, patients, families, and physicians. Supports departmental and Cherokee Nation Health Services strategic plans, and ensures successful implementation. Supports Cherokee Nation Health Services Quality Assurance (QA)/Quality Improvement (QI) initiatives. Maintains acceptable production and quality assurance standards. Works effectively in an independent environment. Uses strong interpersonal/human relationship skills, both oral and written, in order to provide exceptional customer service. Maintains a positive attitude in the work place. Directs patients' inquires to the appropriate personnel. Provides quality customer service by being available for scheduled shifts; including arriving promptly and completing shifts as needed to meet demands of daily call levels. Ensures patient advocacy focus. Other duties may be assigned.

SUPERVISORY RESPONSIBILITIES   

This job has no supervisory responsibilities. 

EDUCATIONAL REQUIREMENT 

High school diploma or general education degree (GED) and less than one year of specialized training or education.

EXPERIENCE REQUIREMENTS

At least six months experience in a related field.

COMPUTER SKILLS

An individual should have knowledge of Internet, Spreadsheet, and Word Processing software.

CERTIFICATES, LICENSES, REGISTRATIONS 

National Association of Healthcare Access Management (NAHAM) certification preferred but not required. Certification highly encouraged after one year of service

OTHER SKILLS AND ABILITIES 

Possess strong organizational, problem solving, and decision making skills, and the ability to multi-task and prioritize work.

OTHER QUALIFICATIONS

Employee must not and will not be under sanction by the United States Department of Health and Human Services Office of the Inspector General (OIG) or by the General Services Administration (GSA) or listed on the OIG’s Cumulative Sanction Report, or the GSA’s List of Excluded Providers, or listed on the OIG’s List of Excluded Individuals/Entities (LEIE).

Knowledge of interview techniques and business office billing requirements.

PHYSICAL DEMANDS

While performing the duties of this job, the employee is regularly required to talk or hear.  The employee is frequently required to walk; sit; use hands to finger, handle, or feel and reach with hands and arms.  The employee is occasionally required to stand; climb or balance; stoop, kneel, crouch, or crawl and taste or smell.

WORK ENVIRONMENT

The noise level in the work environment is usually moderate.