Prior Authorization Associate

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Position Overview

The Prior Authorization Associate Level I is responsible for all aspects of the prior authorization process. The individual will be expected to work cross-functionally across many departments (sales, operations, billing, and lab teams) to serve our patient and client needs.

This role will demonstrate knowledge by determining initial and/or ongoing eligibility, coverage in addition to assessing if a prior authorization is needed for reimbursement of a claim. This role will identify deficiencies within the Prior Auth process, assist with triaging, and document actions taken within the systems. This role will be responsible for the working accounts held within the dedicated work queues on a daily basis. This role will also support the broader activities of ensuring appropriate coverage by utilizing Epic, external portals, and other software, and communicate all applicable information to ancillary departments and other teams within the reimbursement operations departments.

Essential Duties

Include, but are not limited to, the following:

• Independently determine initial or ongoing patient insurance eligibility verification, investigate, and correct accounts within Epic; including updates to patient demographics, financial information, and guarantor information.

• Ability to interact with various insurances and third-party payors accurately and timely to ensure authorization is obtained and documented based on internal and external policies and regulations.

• Research missing or erroneous information on accounts using various portals and other resources; including outreach and identification of unknown payors.

• Review/edit claims and appeals prior to submitting to clearinghouse.

• Analyze, research, and resolve claim issues applying federal, state, and payor rules and procedures with a high degree of independence.

• Monitor WQ's for claims that need additional research and actions taken to get on to path of resolution.

• Responsible for CRM support.

• Has exceptional understanding of Claim Edit and Follow Up WQs.

• Utilize Onbase to work documents specific to the TOQ department.

• Correct rejected claims from the claim's scrubber, clearinghouse, or payor.

• Review explanations of payments, analyzes, and completes appropriate steps for all denials by appropriately identifying claim resolution next steps; including appealing, writing off, or sending statements.

• Validate new workflows due to product growth. Additionally, have ownership of the specific WQ's until set up is validated as working effectively.

• Investigate payor underpayments.

• Follow up with payors via phone on unpaid aging claims.

• Provide any supporting documentation needed by insurance payor.

• Perform accurate and timely write-offs following identification of uncollectible accounts adhering to policies and guidelines.

• Provide ad-hoc support, as necessary, within the department (i.e., special projects, provide support due to outages/high volume).

• Complete position responsibilities within the appropriate time frame while adhering to quality standards.

• Stay current with relevant medical billing regulations, rules, and guidelines.

• Maintain strictest confidentiality; adheres to all HIPAA guidelines/regulations.

• Excellent problem-solving abilities and organizational skills.

• Ability to communicate effectively with all levels of staff through both verbal and written communications.

• Ability to work in a team environment.

• Ability to adapt to changing workload and circumstances effectively; able to respond to new information quickly.

• Disciplined, self-motivated, and reliable.

• Ability to stay focused on a task and work independently; motivated to perform quality work.

• Diligent about arriving to work on time and completing tasks that are assigned in a timely manner.

• Conducts self in a professional manner in all interactions with members of the Exact Sciences team, clients, and associates.

• Be well-versed in the prior authorization process.

• Ability to complete a high volume of prior authorization requests.

• Possess a positive attitude.

• Work with others in a spirit of teamwork and cooperation.

• Uphold company mission and values through accountability, innovation, integrity, quality, and teamwork.

• Support and comply with the company's Quality Management System policies and procedures.

• Regular and reliable attendance.

• Ability to work a normal schedule Monday through Friday during normal business hours.

• Ability to work in front of a computer screen and/or perform typing for approximately 90% of a typical working day.

• Ability to work on a computer and phone simultaneously.

• Ability to use a telephone through a headset.

• You will be required to successfully complete an assessment showing understanding of Exact Sciences Epic processes necessary to the job functions with a score of 80% or higher. Exact Sciences will make reasonable accommodations available, if necessary, to assist an employee with a disability to satisfy this requirement.

Minimum Qualifications

• High School Diploma or General Education Degree (GED).

• 2+ years directly involved in the submission and follow up of Prior Authorization workflows.

• 3 years of experience in medical billing, claims, and/or insurance processing.

• Extensive and current working knowledge of government, managed care, and commercial insurances claim submission requirements, reimbursement guidelines, and denial reason codes.

• Knowledge of medical terminology and/or health insurance terms.

• Knowledge of EHR operating systems and work involving electronic records.

• Proficient in computer systems and keyboarding skills.

• Demonstrated strong attention to detail and focus on quality output.

• Demonstrated ability to perform the Essential Duties of the position with or without accommodation.

• Authorization to work in the United States without sponsorship.

Preferred Qualifications

• Related Associate degree or medical billing certification.

• 5+ years of experience in medical, laboratory or insurance billing fields.

• Experience with Epic or other EHR application.

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Salary Range:

$40,000.00 - $65,000.00

The annual base salary shown is for this position located in US - WI - Madison on a full-time basis and may differ by hiring location. In addition, this position is bonus eligible, and is eligible to receive company stock upon hire as well as annually.

Exact Sciences is proud to offer an employee experience that includes paid time off (including days for vacation, holidays, volunteering, and personal time), paid leave for parents and caregivers, a retirement savings plan, wellness support, and health benefits including medical, prescription drug, dental, and vision coverage. Learn more about our benefits.

Our success relies on the experiences and perspectives of a diverse team, and Exact Sciences fosters a culture where all employees can develop personally and professionally with a sense of respect and belonging. If you require an accommodation, email hr@exactsciences.com. We'll work with you to meet your accessibility needs.

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We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to age, color, creed, disability, gender identity, national origin, protected veteran status, race, religion, sex, sexual orientation, and any other status protected by applicable local, state, or federal law. Any applicant or employee may request to view applicable portions of the company's affirmative action program.

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