SUMMARY

The Prior Authorization Specialist is responsible for all aspects of the prior authorization process. Responsibilities include collecting all the necessary documentation, contacting the client for additional information and completion of the required prior authorization in order to proceed with testing.  Complete, timely, and accurate identification and submission of prior and retro authorization requests to the payors. Interacts with clients, insurance companies, patients, and sales representatives, as necessary, to request for prior authorizations.  Responsible for documenting account activity, updating patient and claim information and demonstrates proficiencies with the XIFIN billing system to ensure all functionalities are utilized for the most efficient processing of claims and identifies prior authorization trends and/or issues resulting in delayed claims processing. Provides the highest level of customer service to internal and external clients. 

SECTION I:  JOB QUALIFICATIONS

1.      Minimum of 2 years of customer service experience in the healthcare industry preferred.

2.      Proficiency in XIFIN billing system preferred.

Education (Select only those that apply, otherwise Not Applicable)

  High School Diploma or GED

certification

Medical billing certificate a plus.

licensure

Not Applicable

SECTION ii:  Required Knowledge, Skills or Abilities 

Computer Skills

1.     Knowledge of basic computer skills such as Microsoft Office Suite (Outlook, Word, Excel, Sharepoint, etc.).

2.     Previous experience with clinical laboratory billing software such as XIFIN, preferred.

Language Skills

1.     Ability to effectively present information and respond to questions from management, clients, auditors and internal customers.

SECTION iii:  Job Specific Requirements 

1.     Performs daily activities of billing and auditing of accounts to ensure accurate claims submissions and to optimize reimbursement for patient treatment from clients, commercial/government payers and patients.

2.     Document eligibility, benefit and authorization information in accordance with established guidelines. 

3.     Research patient accounts due to invalid and/or missing authorization information and correspond with clients, insurance companies, patients, sales representatives to obtain the necessary information to ensure accurate, timely and complete claims submissions.

4.     Verify prior authorizations and/or pre-service requirements are met.

5.     Proactively manages and maintains all outstanding authorization accounts to increase billing of clean claims.

6.     Provide outstanding customer service to patients and develop and maintain positive working relationships with internal and other external customers.

7.     Identify and report trends and prior authorization issues relating to billing and reimbursement.

8.     Document all account activity and correspond to inquires in a timely manner.

9.     Reviews accounts on a daily basis while meeting or exceeding all daily, weekly and monthly production goals.

10.  Communicates and works effectively with colleagues from other departments.

11.  Follows written and verbal communications.

12.  Follows all MDxHealth's health and safety policies and procedures.

13.  Performs other related duties as required or assigned.

SECTION iv:  PROFICIENCY TESTING

Not Applicable

SECTION V:  WORK ENVIRONMENT (SELECT ALL APPLICABLE OR NOT APPLICABLE)

 Corporate Office Environment

 Use of Stairs (Alton Facility)

 Travel between Office Locations

SECTION VI:  Physical Demands

While performing the duties of this job, the employee is regularly required to use hands to finger, handle or feel.  The employee is required to sit and stand during the duration of their shift.  The employee must on occasion lift and/or move up to 10 - 25 pounds.  Specific vision abilities required by this job includes close vision, distance vision, color vision, depth perception, and ability to adjust focus.

SECTION VII:  OSHA RISK CATEGORY (SELECT ONE)

 Category III:          Job tasks that do not involve exposure to blood, body fluids, tissues, hepatitis viruses or human immunodeficiency viruses.

SECTION VIII:  Safety

1.     Responsible for performing assigned tasks in accordance with applicable safety regulations and instructions, as well as correcting unsafe work habits and practices and/or bringing to the attention of the Laboratory Director, Safety Representative, a Manager/Supervisor, Human Resources, Quality Management any practice or condition that may be detrimental to the safety and health of employees.

2.     Responsible for compliance to all safety policies of the MDxHealth safety program.

3.     Follows procedures for biohazardous/hazardous waste disposal.

4.     Utilizes appropriate infection control practices such as hand-washing, proper glove disposal, use proper personal protective equipment and work practice controls.

5.    Maintains proper body mechanics and utilizes safe work practices.

SECTION IX:  Regulations & Compliance 

1.     Responsible for compliance to all applicable statutory and regulatory requirements for international, federal, and state requirements, including, but not limited to, California Labor Laws, OSHA, Clinical Laboratory Improvements Amendments (CMS), Americans Disabilities Act, Health Insurance Portability and Accountability Act (HIPAA/Omnibus), MDxHealth OIG Compliance Program, College of American Pathologists, California State Department of Public Health, New York State Department of Health, ISO 9001:2008, U.S. Food and Drug Administration.  (Refer to the MDxHealth Quality Systems Manual for a complete listing).

2.     Takes responsibility for supporting the College of American Pathologists Patient Safety Goals.

3.     Responsible for reporting to the College of American Pathologists any concerns regarding quality patient testing or laboratory employee safety that are not being addressed by MDxHealth.

4.     Exhibits ethical and professional behavior at all times.

5.     Maintains patient confidentiality at all times (HIPAA).

Supervisory Responsibilities 

Not Applicable