POSITION SUMMARY

Performs prior authorization/certification of scheduled services with payers. Provides clinical review and document submission of pre-certification requests for scheduled elective services.

ACCOUNTABILITIES

Performs clinical review and document submission to obtain pre-certification/authorization requests for orthopedic surgeries and injections. Completes consistent review of individual payer policies to identify changes affecting pre-certification authorizations. Maintains current working knowledge on medical criteria relating to prior authorization requirements by third party payers and medical necessity requirements. Participate in process development and improvement as it relates to obtaining authorizations, communication, education, etc. General understanding of coding for surgeries and injections to be able to communicate and document medical necessities for procedures. Thoroughly documents actions and resolutions taken in appropriate information system(s). Additional responsibilities/duties will be assigned based on teamwork load and competency