Clinical Lead, Prior Authorization (Home Health)

The Clinical Lead, Prior Authorization is responsible for performing all job duties as a patient service representative and lead member of the team. To serve as a resource person and mentor to the staff. The Clinical Lead, Prior Authorization is responsible for collaborating with all members of the healthcare team.

Job Relationships

Reports to the Manager

Principal Responsibilities

• Function as a resource during the planning and implementation of projects within the department.
• Assist the Managers with day-to-day planning and scheduling of staff. Demonstrate willingness to provide staffing during critical staffing times.
• Provide direct oversight and maintenance of department Quality Assurance Pre-cert statistical information. Provide and summarize clinical performance data to the as requested.
• Assist with development and maintenance of insurance precertification policies and procedures in the TeleNurse department.
• May serve as department preceptor.
• Must have an interest in technology and its applications for improving patient care.
• Coordinate/lead the Insurance Precertification Program.
• Stay up-to-date on insurance changes and requirements for pre-certifications.
• Train staff on precertification program/processes and answer their questions on a daily basis as needed.
• Act as a liaison with the physician offices, accept feedback, and train Operations staff members as needed on pre-certifications.
• Responsible for tracking all statistical precertification data. Include tracking of revenue gain/loss for complete/incomplete pre-certifications.
• Assist in curriculum development and coordinate the orientation and training programs for new and experienced staff members.
• Work collaboratively to coordinate educational In-services for staff
• Assist in monitoring staff education compliance and completion of mandatory requirements. Assist with the development of department competencies.
• Prepare and present educational information to staff and develop educational intranet site for within the department.
• Comply with the Springfield Clinic incident reporting policy and procedures.
• Adhere to all OSHA and Springfield Clinic training & accomplishments as required per policy.
• Provide excellent customer service and adhere to Springfield Clinic's Code of Conduct and Ethics Standards.
• Perform other job duties as assigned.
• Responsible for collaborating with all members of the healthcare team to anticipate and address educational needs.

Education/Experience

• Minimum of three (3) years of clinical experience in an acute ambulatory or acute care setting required.
• Experience and competency in training, evaluation, mentoring, and project development preferred but not required.
• Experience with Prior authorizations preferred but not required.
• Experience with healthcare clinical applications strongly preferred.

Licenses/Certificates

• LPN license required within 90 days of hire

Knowledge, Skills and Abilities

• Ability to type at least 40 words per minute.
• Proficiency in Microsoft Word, PowerPoint, and Excel and strong computer skills.
• Excellent written, verbal, and interpersonal communication skills.

Working Environment

• Operates in a professional office environment with a potential for work from home opportunities.
• Routinely uses standard office equipment such as computers, phones
• Requires the ability to sit for extended periods.

PHI/Privacy Level

• HIPAA1