Job Description

Job Description

We are currently recruiting a full-time Authorization Specialist. A prior authorization specialist assists patients who need treatment requiring insurance carrier pre-authorization. They liaise with insurance companies and nurse managers for prior authorization approval.   This is NOT a remote position.

Orthopedic Institute has been serving the region for over 40 years offering excellent orthopedic care across South Dakota, Western Minnesota, and Western Iowa.

Our history has been marked by partnerships built on shared values and vision. We have recently added physicians to strengthen our position as an independent practice.  We focus solely on exceptional orthopedic care to broaden the reach and impact in this region. Our provider team has grown to include 22 physicians and 20 physician assistants/nurse practitioners and over 230 employees. We currently have locations in Sioux Falls, Brookings, Mitchell and Yankton and numerous outreach locations in the region.

Responsibilities:

• Verify and document insurance eligibility; confirm and document benefits.
• Review and submission of clinical documentation to ensure the treatment/services are appropriate for the diagnosis as determined.
• Obtain and verify that insurance authorizations are obtained and maintained on designated patients.
• Ensure that initial and all subsequent authorizations are obtained in a timely manner.
• Work to reduce and eliminate authorization denials.
• Reviews and interprets pertinent medical record documentation for patient history, diagnosis, and previous treatment plans to pre-authorize insurance plan determined procedures to avoid financial penalties to patient, physician, and facility.
• Utilizes payor-specific criteria to determine medical necessity for the clinical appropriateness for a broad scope of services and procedures considered effective for the patient's illness, injury, or disease.
• Obtains appropriate diagnosis, procedure, and additional service codes to support medical necessity of services. 
• Submits pertinent demographic and supporting clinical data to payor to request approval for services being rendered.
• Provides referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive administrative time required of providers.
• Maintains compliance with departmental quality standards and productivity measures.

Qualifications: 

• High School diploma or equivalent with four years working experience in a medical environment ( such as a hospital, doctor's office, or ambulatory clinic) OR an associate degree and two years of experience in a medical environment required.
• Completion of a medical terminology course (or equivalent)  or has 3 years of experience working in the medical field required
• Baseline knowledge and interpretation of medical terminology and codes
• Proficient in Microsoft Office applications
• Excellent communication and interpersonal skills
• Ability to analyze data and use independent judgment
• Understanding of authorization processes, insurance regulations, third party payors, and reimbursement practices
• Experience utilizing an EMR (Electronic Medical Record) or medical office experience required.
• Orthopedic experience preferred. 
• Medical terminology, knowledge of insurance processes and customer service required.

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