Crawford Memorial Hospital

The Prior Authorization/Referral rep is responsible for providing indirect patient care through completion of practitioner ordered referrals and prior authorizations.. Responds quickly and accurately to assist all clinic offices with referral and prior authorization tasks.. Completes pre-certification for testing/procedures; ensure notification of pre-certification for each patient is completed in a timely manner.. Provides supplemental information to insurance companies and practitioners/facilities to obtain pre-certification or a referral appointment.. Current (CCMA) Medical Assistant Certification or HIM Degree/Certificate required

prior authorization

Position: Prior Authorization/Referral Rep
Department: Clinics
Reports To: Clinical Clinic Manager
Direct Reports: None
FLSA Classification: Non-Exempt

Position Summary
The Prior Authorization/Referral rep is responsible for providing indirect patient care through completion of practitioner ordered referrals and prior authorizations. Works closely with insurance companies to obtain authorization prior to scheduled surgeries and tests to ensure proper payment for such procedures. Establishes appointments for patients needing referral to an outside facility for continuation of care and/or specialty care. Supplies additional required information as needed to insurance companies and facilities to complete required tasks. Responds quickly and accurately to assist all clinic offices with referral and prior authorization tasks.

General Duties, Tasks and Responsibilities
Follows medical records documentation guidelines regarding timeliness of reviews and completeness of documentation; obtains and documents accurate and thorough patient medical history including pertinent history, pain assessment, current medications, identified health risk factors and other needed information.
Completes pre-certification for testing/procedures; ensure notification of pre-certification for each patient is completed in a timely manner.
Performs all aspects of the position in an environment that optimizes patient safety and reduces the likelihood of medical/healthcare errors; utilizes established hand-off communication protocols; maintains the security of the department.
Obtains proper authorization; follows medical records documentation guidelines regarding timeliness of reviews and completeness of documentation.
Works with patient to establish a referral appointment for the specialty or facility indicated by the ordering practitioner.
Provides supplemental information to insurance companies and practitioners/facilities to obtain pre-certification or a referral appointment.
Communicates established appointments and details with patients upon completion of a referral appointment.
Completely and accurately documents all communication with insurance companies, facilities, and patients.
Complies with all established safety procedures to ensure a safe environment for patients, visitors and staff.
Participates in performance improvement activities
Performs other duties as assigned

Education Requirements
Completion of an accredited Medical Assistant Program or HIM Degree/Certificate required

Certification/Licensure Requirements
Current (CCMA) Medical Assistant Certification or HIM Degree/Certificate required
BLS Required

Experience Requirements
CCMA/HIM minimum 1 year Preferred
Physician Office minimum 2 years Preferred

Computer Skills
Strong computer skills including Microsoft Excel and Outlook

Additional Skills
Excellent communication and customer service skills
Strong interpersonal, organizational and time management skills
Ability to work independently, prioritize and complete tasks in a timely manner

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