Prior Authorization Analyst - Finance_ Revenue Cycle

Cook County Health

Full-time

Hospitals

About the position

The Prior Authorization Analyst plays a crucial role in the Finance/Revenue Cycle department, focusing on the management and analysis of prior authorization processes. This position is exempt from Career Service under the CCH Personnel Rules and is designed to support strategic initiatives aimed at reducing authorization denials through process redesign and root cause analysis. The analyst will serve as a primary resource for understanding and navigating prior authorization requirements, ensuring that patients receive necessary services while maintaining compliance with insurance protocols. In this role, the analyst will analyze prior authorization denials reports to identify detailed reasons for denials, including issues related to inaccurate or missing information. The analyst will work closely with management to evaluate changes from payers that may impact reimbursement processes. Recognizing billing errors and knowing when to submit reconsideration requests for payment with appropriate documentation is essential. The analyst will also review denial reports for patterns, particularly from specific insurance carriers, and collaborate with contract staff to address identified errors. The position requires a proactive approach to ensure that patients receive services requiring prior authorization by addressing rejected claims that need additional documentation or peer consultations. The analyst will collaborate with various departments to facilitate the acquisition of prior authorizations and will be responsible for completing data reviews and reporting on metrics and trends related to authorization denials. Maintaining an audit trail of changes to authorization requirements is critical for supporting root cause analysis and appeals processes. Additionally, the analyst will develop and maintain strong working relationships with hospital departments and referring physicians to gather necessary information for successful appeals or reversals of authorization denials. Staying current with insurance changes and prior authorization requirements is vital for success in this role. The analyst will also be expected to attend meetings and perform other duties as assigned by the Director of Pre-Patient Access.

Responsibilities

• Analyzes the prior authorization denials report to identify reason for denials in detail including inaccurate and/or missing information.
• Works closely with management to evaluate payer changes or other items that may impact reimbursement affected by prior authorization.
• Recognizes billing errors and when to submit a reconsideration request for payment with all appropriate documentation.
• Analyzes denial reports and recommend changes to workflow as appropriate with impacted departments on any deficiencies in workflow or system build.
• Reviews denials report for patterns related to repeated denials from a particular insurance carrier.
• Ensures patients receive the services that require prior authorization from insurance carriers by addressing and rectifying rejected claims that require additional documentation and/or Peer to Peer Consultation.
• Collaborates with other departments to assist in obtaining prior authorizations.
• Completes data review and reports on metrics/trends of authorization denials.
• Maintains an audit trail of changes to authorization requirements to assist with root cause analysis and support cause for appeals.
• Develops and maintains a strong working relationship with hospital departments and referring physicians to collaborate in obtaining information needed for successful appeal/reversal of authorization denial.
• Maintains a current knowledge related to insurance changes and requirements for prior authorization.
• Gathers data, performs a detailed review, and submits a report based on findings, as directed.
• Attends and participates in meetings, as needed.
• Performs other duties as assigned by the Director of Pre-Patient Access.

Requirements

• Licensed as a Registered Professional Nurse in the State of Illinois
• Two (2) years of nursing work experience
• One (1) year of work experience in Utilization Management/Prior Authorization in a physician group, insurance company or management services organization
• Prior experience identifying trends in prior authorization and denial prevention, i.e., incomplete coding, lack of documentation

Nice-to-haves

• Care management or medical insurance experience
• Bachelor's degree in nursing from an accredited college or university
• One (1) year experience with electronic medical records (EMR)
• Prior experience using InterQual or Milliman criteria sets