01Responsibilities
Ensure accurate validation of insurance eligibility, coverage details, network agreements, and financial obligations.
Obtain, track and complete prior authorizations, validate imaging, testing, procedure meets insurance company medical necessity criteria across various specialties. This encompasses outpatient services and surgical/non-surgical procedures, whether elective, urgent, and same day.
Interact with physicians, nurses and clinical support staff on a case-by-case basis to obtain appropriate clinical documentation to ensure accurate indications in the patients medical record before completion of third-party prior authorizations. This may include contacting referring physicians for information.
Understand, anticipate, and respond to complex questions from clinical staff and insurance company nurse reviewer. When necessary, proactively contact third parties and initiate communication to ensure appropriate future payment.
Problem solves with insurance utilization review nurses, medical directors, providers, and other Iowa Healthcare staff to meet patient care needs. Identify and produce creative solutions to problems identified via the prior authorization process.
Appeal prior authorization denials and/or set-up peer to peer reviews.
Communicate with clinical teams on non-covered procedures/therapy/testing or exam .
