Manager, Prior Authorizations

POSITION SUMMARY:

Effectively leads the Prior Authorization functional area within billing, collection or accounts receivable management, maintaining a full understanding of the billing information system. Manages the activities of staff through daily supervision while overseeing designated functional area across revenue cycle including but not limited to billing and pre-certification. Assists with implementing strategic goals by deploying internal and external staff.

PRIMARY RESPONSIBILITIES:

• Manages large teams, including supervision of staff for a pre-certification denials and appeals team.

• Assists with hiring, disciplinary actions, and performance evaluations

• Provides department orientation and ongoing training for all in/direct reports.

• Directs self and others in areas of responsibility such as research, appeals, pre-certification, payor policy and eligibility.

• Liaison with internal departments to promote ongoing communication, and collaboration on cross functional projects related to prior authorization.

• Analyze prior authorization outcomes including payor reimbursement exception reporting, appeal follow up analysis and denials management.

• Utilize billing expertise in the system to investigate and analyze insurance payor requirements for prior authorization, ensuring compliance and streamlined approvals.

• Partner cross-functionally with Market Access, Sales, Billing Strategy, and Clinical teams to ensure alignment on prior authorization workflows, payer policy adherence, and reimbursement optimization strategies, with the shared goal of improving overall patient access

• Represent organizational projects and assist management with follow-through and implementation of initiatives.

• Monitors and validates adherence to Policies and Procedures, auditing as necessary.

• Monitors and evaluates employee productivity and performance to goal.

• Builds employee morale, motivation and loyalty by fostering positive working relationships.

• This role works with PHI on a regular basis both in paper and electronic form and has access to various technologies to access PHI (paper and electronic) in order to perform the job.

QUALIFICATIONS:

• Bachelor’s Degree in related field or equivalent required

• Minimum of 5 years of experience in managing a high volume, fast growing billing office within the laboratory setting is preferred.

• Extensive knowledge of payor reimbursement, billing, coding and compliance regulations is required.

KNOWLEDGE, SKILLS, AND ABILITIES:

Training in fields such as business administration, accountancy, sales, marketing, computer sciences or similar vocations. Normally requires a minimum of two (2) years directly related and progressively responsible experience. Ability to perform complex analysis and discuss with upper management. Skilled in Microsoft Office: Word and Excel. Ability to communicate effectively both orally and in writing. Strong interpersonal skills. Strong organizational skills, including attention to detail. Knowledge of payer eligibility and benefits. Health care research and analysis skills sufficient to support payer research healthcare policy library and state management. Ability to resolve associate issues effectively and efficiently.

PHYSICAL DEMANDS & WORK ENVIRONMENT:

Duties are typically performed in an office setting. This position requires the ability to use a computer keyboard, communicate over the telephone and read printed material. Duties may require working outside normal working hours (evenings and weekends) at times.