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Orthopedic ONE · 2 months ago

Prior Authorization/Workers Compensation Specialist

Westerville, OH

Full-time

Onsite

Entry Level

2+ years exp

Orthopedic ONE is a healthcare provider specializing in orthopedic care, and they are seeking a Prior Authorization/Workers Compensation Specialist. The role involves obtaining pre-certifications and authorizations for various medical procedures, managing worker's compensation claims, and providing excellent customer service to patients and insurance providers.

Health CareHospitalMedicalTherapeutics

Responsibilities

Receives queries for pre-certification for diagnostic testing (MRI, EMG, CT, etc.), medication (Synvisc, NSAID, cox-2), surgery and physical or occupational therapy including documentation of ICD-10 and CPT codes

Contact insurance provider to obtain authorization numbers if pre-certification is required. If surgical procedures are involved, documents the days allowed for inpatients and sends information to appropriate hospital or surgery center

Generates pre-certification/authorization case management information in the EMR system noting authorization number, notes and date of service information. May also make relevant notes in patient information screens and apply information to surgery date of service or appointment

Generates reports from EMR to prompt a review for changes or cancellations one week prior to procedure

Provides phone coverage of the department hotline to support physician offices with same or next day requests or questions

Receives referrals and enters information into EMR system including authorization numbers, primary care physician, visits allotted and expiration date or other notes pertaining to insurance plan

Prints physician schedules 24-48 hours in advance and reviews patient information for referrals to ensure it prints on encounter form for appointment

Researches missing information by contacting patient, PCP or insurance providers

Reviews appointment schedules 24 to 48 hours in advance for assigned physicians to identify worker's compensation patients

For new patients, reviews referrals and searches BWC web-site for claim number, allowed and billable information, ICD-10 codes, date of injury and other relevant information. For established patients, reviews BWC information for updates

Creates case information in EMR system for documentation purposes

Creates and maintains documentation as required for worker's compensation claims such as C-9, MEDCO 14, C-31, etc

Communicates with Managed Care Organization Case Managers as needed to obtain or provide information for treatment

Communicates with patients, insurance carriers and other outside entities in a professional manner. Identifies solutions and responds professionally to patient concerns, i.e., pleasant tone of voice, courteous language, etc. Uses appropriate grammar and demonstrates tact and diplomacy in patient interactions, by phone and in person

Diffuses negative situations with patients and maintains a pleasant and professional tone during stressful circumstances and heavy workload

Communicates with staff members in a professional, pleasant manner; Shares information relevant to work, no gossiping or disparaging remarks, accepts work without complaint or provides reasons why assignment is unmanageable, asks and answers questions related to improving department performance

Willingly provides coverage, volunteers assistance, and maintains workflows within department as needed without direct instruction/supervision

Works cooperatively and refrains from participating in negative conversations

Shares knowledge and insights with co-workers in a constructive manner

Works to solve problems and address conflicts with appropriate person directly before involving leadership or uninvolved peers

Is considerate of others in the work environment with regard to taking breaks or meal periods, use of computer and phone, noise level in the department, etc

Knows and complies with policies and procedures as enumerated in the Orthopedic One Employee Handbook and policies and procedures documents

Provides assistance and support to leadership in implementing policies and procedures as necessary

Actively participates in training, and conducting day to day work activity by adhering to all policies and procedures as enumerated in compliance and risk management programs

Qualification

Medical Billing ExperienceInsurance AuthorizationEMR System ProficiencyHealth Information ManagementCustomer ServiceCommunication SkillsAttention to DetailTeamwork

Required

High School Diploma or equivalent required

Minimum of two years of medical billing experience which includes insurance authorization (prior authorization, pre-determinations, pre-certifications, etc.) and worker's compensation

Computer skills required to operate practice management system (i.e., use Window operating system, conduct Internet searches, communicate by email, etc.)

Ability to tolerate a high volume of work while maintaining attention to detail and accuracy

Excellent oral and written communication skills