Health Management Extender - Spartanburg Regional Healthcare System

Position Summary

Under the direction of the Director of Case Management, the Prior Authorization Extender (PAE) serves in a collaborative role to the Case Manager and the payors. The PAE is responsible for accurately authorizing referrals to post-acute facilities from our acute care campuses. They will collect necessary documentation and communicate with third party payers, case managers, and patients to prioritize requests. The PAE must be able to prioritize, multi-task and perform work with a high degree of accuracy to achieve timely and efficient management of post-acute referrals requiring prior authorizations.

Minimum Requirements

Education

• Associate Degree

Experience

• 3 Years: Healthcare, financial services, care coordination, and/or utilization management experience, Certified Medical Assistant, LPN, or bachelor’s degree with no post degree experience

License/Registration/Certifications

• N/A

Preferred Requirements

Preferred Education

• Associate Degree

Preferred Experience

• 3-5 Years

Preferred License/Registration/Certifications

• N/A

Core Job Responsibilities

• Complies with established policies and procedures
• Responsible for preauthorization for transfers to post-acute facilities
• Complies with regulatory requirements of discharge planning and utilization management
• Collect, maintain, and on occasion present data gathered regarding prior authorization process and any delay of discharge due to process
• Thoroughly reviews patient charts in Epic, submits the appropriate clinicals for authorization to the correct payer/third party vendor, obtains final determination from payer and enters information into EPIC.
• In collaboration with the discharge planning case manager, PAE will complete necessary documentation required for peer-to-peer in the case of an appeal to a declined prior authorization if applicable
• Assist with the implementation function of the plan of care as developed by the case manager to provide effective communication and timely services
• Responsible for obtaining appropriate insurance verification, prior approval, and all authorization requirements prior to a patient’s discharge to post-acute facility
• Seeks case manager clarification and communicates with professional staff on the plan of care and continued stay
• Must be self-directed to refer difficult placements or placements with no bed offers to the case manager; CME will ensure information is updated and resent to avoid delays
• Serves as an information conduit between SRHS and external agencies/facilities, providers and payors ensuring information is communicated to the next venue of care.
• Updates knowledge by participating in educational opportunities and attending staff meetings
• Documents clearly and concisely all contacts and information of the patient’s case management process in the medical record
• In case of a QIO appeal, assists the case manager and/or Office Manager in copying of the medical record and printing of electronic information from the medical record.
• Other duties as assigned

PI254010965