Prior Authorization Rep - Novitas - Remote, FL

Are you interested in joining a team of experienced healthcare experts and have the ability to shape and transform the healthcare delivery system? At our family of companies, everything we do is to help improve the lives of the nearly 12 million Medicare beneficiaries we serve and 700,000 health care providers who care for them. It is our goal to help create a better health experience for all consumers. Join our winning culture and help transform Medicare for the millions of people who rely on its services.

Benefits info:
* Medical, dental, vision, life and supplemental insurance plans effective the first day of the month following date of hire
* Short- and long-term disability benefits
* 401(k) plan with company match and immediate vesting
* Free telehealth benefits
* Free gym memberships
* Employee Incentive Plan
* Employee Assistance Program
* Rewards and Recognition Programs
* Paid Time Off and Paid Sick Leave

SUMMARY STATEMENT

The Prior Authorization Rep reviews Part A and Part B Prior Authorization Requests (PARs) and Review Choice Demonstrations (RCDs) receipts and performs claim processing for any stopped claims. This role performs data validation, drafts correspondence, and finalizes cases within the workflow system, ensuring all activities are completed according to CMS mandates. In addition, the Prior Authorization Rep completes timely claim adjudication/adjustment for all Part A and Part B pre-payment and post payment claims per Centers for Medicare & Medicaid Services (CMS) requirements post clinical review.

ESSENTIAL DUTIES & RESPONSIBILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.

Prior Authorization Request (PAR)/Pre-Claim Review (PCR): (80%)

* Reviews the case and received documentation in the Prior Authorization (PA) workflow system to identify the beneficiary and provider and ensures all fields are completed and accurate

* Researches and validates the beneficiary and provider in the appropriate Medicare Part A and Part B processing systems, Fiscal Intermediary Shared System (FISS), Health Insurance Mainframe Repository (HIMR), Multi-Carrier System (MCS), and Medicare Provider, Enrollment, Chain, and Ownership System (PECOS) systems.

* Obtains missing information from providers as needed

* Prepares Prior authorization requests for clinician review as needed and creates detailed decision letter sent to the provider and beneficiary using the PA workflow system

* Ensures all correspondence to the provider is sent within our timeliness standards for all standard and expedited requests.

* Finalizes the Prior Auth request in the PA workflow system, ensuring fax confirmations are attached and CMS established timeliness requirements are met

Pre-Pay/Post Pay Claim Processing: (10%)

* Researches claim information required for different work processes in the propriate Medicare Part A and Part B claims processing systems, Fiscal Intermediary Shared System (FISS) and Multi-Carrier System (MCS)

* Consults with and assists the Clinical Review Nurse (CRN) regarding appropriate claim payment decisions

* Adjusts/adjudicates claims in accordance with their decisions, ensuring the CMS timeliness guidelines are met

* Monitors and tracks claim suspension through the claims processing systems until finalized

* Researches and resolves claim edit /audit suspension issues

* Completes the necessary letter communication to the provider in collaboration with the clinical reviewer based on the outcome of the review

Suspended Claims Processing: (10%)

* Researches claim information for different work process in the appropriate Medicare Part A and Part B claims processing systems, FISS or MCS according to established guidelines

* Researches and resolves claims processing, claims movement (within locations), and claim edit/audit suspension issues

* Suspends claims in the claims processing systems in response to edit/audit development and implementation

* Monitors and tracks claim suspension through the claims processing systems

* Moves claims in the claims processing systems locations, as appropriate

Performs other duties as the supervisor may, from time to time, deem necessary.

REQUIRED QUALIFICATIONS

* High School diploma or GED

* 2 years' experience utilizing research skills in reading and interpreting information.

* Basic proficiency with Microsoft Suite (Excel, Word, SharePoint, and Outlook) and other PC software applications

* Demonstrated verbal and written communication skills.

* Demonstrated customer service skills.

* Proven ability to organize and prioritize multiple work assignments and meet deadlines.

* Demonstrated ability to make independent decisions relying on various on-line reference tools

PREFERRED QUALIFICATIONS

* 2 years related work experience; this includes Medicare, claims processing, or medical background.

* An understanding of the relevant "standard/shared" (i.e. MCS/FISS) and departmental systems

* Knowledge of departmental software systems, workflows, and tools

The Federal Government and the Centers for Medicare & Medicaid Services (CMS) may require applicants to have lived in the United States for a minimum of three (3) years out of the last five (5) years to be employed with the Company. These years of residence do not have to be consecutive.

"We are an Equal Opportunity/Protected Veteran/Disabled Employer."

This opportunity is open to remote work in the following approved states: AL, FL, GA, ID, IN, IO, KS, LA, MS, NE, NC, ND, OH, PA, SC, TN, TX, UT, WV, WI, WY. Specific counties and cities within these states may require additional approval. In FL and PA in-office and hybrid work may also be available.