Job Description

UPMC Community Medicine Incorporated is hiring a full-time Authorization Specialist to assist Tri-Rivers Musculoskeletal Centers located in Wexford. The Authorization team is a team of 5 that helps assists 50+ providers over multiple offices and facilities. This is a Monday-Friday, daylight position with the opportunity for a hybrid work schedule.

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 responsibilities:
  • 1. 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 Services 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 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 responsibilities
  • 1. Resolves basic authorization edits to ensure timely claim filing and elimination of payor rejections and or denials.

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