Job description

Thundermist's Mission - To improve the health of our patients and communities by delivering exceptional health care, removing barriers to that care, and advancing healthy lifestyles.

Please note, effective September 1,2021, all Thundermist employees are required to have an initial dose of vaccine to prevent Covid-19. Effective October 1, 2021, all employees of RI licensed health care facilities must be fully vaccinated against Covid-19. Employees may be deemed exempt from this requirement based on documentation from their health care provider.

Title: Prior Authorization Coordinator

General Responsibilities:
The Prior Authorization Coordinator performs all functions necessary to process, obtain, and close prior authorizations in an accurate and timely manner. They will complete all documentation/forms and communicate information accurately to external providers/entities to ensure a high-quality patient experience. The coordinator will maintain accurate records and update providers and patients as needed throughout the process.

Qualifications: Required Qualifications:

• High School graduate/diploma.
• Organizational skills
• Computer literate
• Excellent telephone/customer service skills
• Ability to work independently and with a team

Preferred Qualifications:

• Post-secondary training in Medical Assistant Program/Professional School
• Bi-lingual in English and Spanish
• 1-year experience working with prior authorizations/referrals
• Candidates who do not meet all of the preferred qualifications are encouraged to apply.

Significant Job Functions:

• Process urgent and routine referrals/prior authorizations within expected timeframes
• Meet with patients to schedule appointments, confirm preferred facility/specialist, update insurance, and assist with referral/prior authorization questions including providing proper documentation to patient
• Advise patients of referral/prior authorization process and timeline
• Recognize and utilize the preferred processes for specialists
• Act as a liaison with pharmacies, insurers, and rendering facilities
• Timely outreach to specialist offices/other to obtain consult notes following patient visits to close out pending referrals
• Document in patient record regarding appointment date, consult note status, and prior authorization status updates
• Monitor all prior authorization queues, perform patient outreach, and identify barriers to bring referral/prior authorization to completion
• Perform and clearly document appropriate patient outreach and action taken to ensure timely completion of referral/prior authorization
• Respond by the end of the day to incoming telephone encounters and voicemail queue in order to provide updates and bring issues to resolution
• Clearly and concisely document actions taken in patient record
• Provide patient with referral/prior authorization coordinator contact information to further assist with questions and/or the referral process
• Outreach to specialist offices to inquire about services, determine wait times for visits, and to determine referral policies
• Ensure that patient clearly understands the process, expectations, and timeline of the office to which they are being referred
• Obtain required documents (i.e., labs, DI, progress notes, etc.,) from EMR for attachment to prior to sending
• Obtain required records (i.e. consult notes, DI, labs, etc.) from external resources utilizing (i.e. Cerner, LifeLinks, Landmark, Current Care, etc.) electronic and other resources to attach to referral
• Create, update, and/or change referral/prior authorization at provider request
• Obtain insurance referral and notes authorization number, dates, and total # of visits allowed prior to sending referral
• Fax clinical notes to insurer when prior authorizations are initiated for patients from another facility
• Monitor queues for prior authorization approval letters then faxes or calls rendering facility, pharmacy, and/or patient with approval information
• Monitor faxes for pharmacy denials and reviews patient records and/or contacts patient to verify list of failed medications, checks plan formulary, confers with THC pharmacist or pharmacy for alternatives for provider approval/denial
• Inform provider/prescriber of denials to determine if an appeal should be submitted and submit appeal if determined appropriate with all accompanying documentation
• Prepare responses to authorization denials within an appropriate timeframe
• Monitor eCW to verify fax confirmations; resend failed faxes
• Research provider information (NPI, address, phone/fax) and CPT codes for out of network for medical prior authorization requests
• For patients with Medicare Part D, contact plan or pharmacy to verify the correct plan and ID number
• Close duplicates and completes process in an open request
• Follow standardized workflows to enable continuity and cross coverage

Physical Effort/ Environment:

• This role is a remote position, duties can be performed from home full time or at a Thundermist site.
• Organizational skills; phone, fax, copier, scanner, computer, writing, and typing.

Work Schedule Demands:

• This is a full-time position, working 40 hours a week. Monday through Friday

Communication Skills:

• Communication with patients, providers, and colleagues on a daily basis.

Confidentiality of Information:
Thundermist is dedicated in securing the privacy and confidentiality of protected health information under the Health Insurance Portability and Accountability Act. It is the responsibility of all employees to comply to state and federal guidelines in accessing sensitive information. The incumbent must apply strict confidentiality.

ADA & EEOC Statement:
Thundermist is dedicated to the goal of building and maintaining a diverse and inclusive workforce committed to caring for patients in a manner that is respectful of cultural difference. We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, gender identity, national origin, disability status, protected veteran status, or any other characteristic protected by law.

Thundermist is dedicated to the goal of building and maintaining a diverse and inclusive workforce committed to caring for patients in a manner that is respectful of cultural difference. We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, gender identity, national origin, disability status, protected veteran status, or any other characteristic protected by law.

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