Authorization Specialist (Children's Hospital of Pittsburgh)

University of Pittsburgh Physicians is hiring a full-time Authorization Specialist to support the Division of Pediatric Ophthalmology, Strabismus, and Adult Motility located at UPMC Children's Hospital of Pittsburgh. This position will work Monday through Friday 8:00am to 4:30pm (no weekends or holidays required)

The Division of Pediatric Ophthalmology, Strabismus, and Adult Motility at UPMC Children’s Hospital of Pittsburgh is comprised of 3 clinic locations and one administrative space, all working as a team to provide the highest level of care to patients and families through clinical expertise, research initiatives, and strong administrative support. 

This position will be responsible for surgical authorizations, out of state authorizations, genetic testing authorizations, and radiology authorizations (and other duties as listed below)

Purpose:
To perform authorization activities of inpatient, outpatient and emergency department patients, denial management and all revenue functions. Need to demonstrate, through actions, a consistent performance standard of excellence to which all work is to conform. The expertise of the Authorization Specialist shall include working knowledge in the area of authorization related activities including pre-authorizations, notifications, edits, denials, etc.The Authorization Specialist shall demonstrate the philosophy and core values of UPMC in the performance of duties.

Responsibilities:

• Prior authorization responsibilities1. Reviews and interprets 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. 2. Utilizes 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. 3. Ensures accurate coding of the diagnosis, procedure, and services being rendered using ICD-9-CM, CPT, and HCPCS Level II. 4. Provides referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive nonclinical administrative time required of providers. 5. Submits pertinent demographic and supporting clinical data to payor to request approval for services being rendered.
• General responsibilities:1. Maintains compliance with departmental quality standards and productivity measures. 2. Works 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.3. Utilizes 18 UPMC system and insurance payor or contracted provider web sites to perform prior authorization, edit, and denial services.4. Utilize authorization resources along with any other applicable reference material to obtain accurate prior authorization.
• Retrospective authorization responsibilities1. Resolves basic authorization edits to ensure timely claim filing and elimination of payor rejections and or denials.