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Job Title: Authorization Specialist

Department: Concierge Services

Position: Full Time

Hours: M-F 9-5

Shift: Day

Req #: 19678

Job Details:

Job Summary:

Authorization Specialist is responsible for procuring payment for outpatient services by financially clearing accounts including specialty units, invasive interventional, clinical procedures and diagnostic testing. Each case is assessed for clinical related concerns and resolved prior to patients presenting to the hospital to ensure a speedy check in and avoid a delay in patient care. The Authorization Specialist is a liaison between the physicians, the OR, frontline registration, specialty areas and all diagnostic departments. Provides excellent customer service and adheres to the productivity performances measure established by the department.

Responsibilities:

Obtains, validates and interprets clinical documentation including orders, H&P, physician progress notes, review lab results, radiology results, assuring all guidelines are met and utilize multiple patient information related systems to obtain/ secure authorization, verify benefits, perform medical necessity checks Performs all levels of registration functions including advising front line registration what is needed to complete the check in process, Document in ConnectCare all financials, payer requirements, clinical documentation and any assistance or alert for the front line registrar. Assists in resolution of denials and billing issues, through extensive research of patients chart including retro authorizations, codes and documentation. Maintains and resolves appointed Account and Patient WQs, Adjust accounts and insurances as necessary utilizing hospital billing functions and applications. Collects demographic and insurance data when applicable ensuring accuracy and completeness. Validate the correct insurance payer is loaded in the HAR. Utilize insurance grids to load correct insurance. Schedule, cancel procedures within the cadence platform. Utilizes pre built Work Queues, Follow-up on any missing documentation, orders, labs or films to ensure a positive patient experience when checking into one of our facilities. Performs any necessary follow-up to include financial responsibility, insurance or authorization issues ensuring a positive patient/physician experience through transparency. Performs eligibility checks on insurance payers using insurance websites, telecommunication and RTE Complete and follow up on the SOR-Scheduled orders report and performs RTE runs for every account the first and 15th of every month.

  • Communicates cooperatively and constructively with patients, area supervisors, families, co-workers, administration, billing, denials, customer service, clinical departments, providers, community agencies, referral sources and other health team members ensuring a positive customer experience.
  • Maintains a high level of accuracy and attention to detail and adherence to current process and workflows to avoid cancellations and denials.
  • Performs other duties as assigned.

Qualifications / Requirements:

Experience:

Minimum 3-5 years of experience in a pre –authorization specialty. Interpretation of physician orders and clinical documentation. Scheduling

Experience:

Extensive Scheduling experience, preps, medication holds and order interpretation Understands resource availability, equipment limitations, and physician suspension.

Education:

Associate’s degree or equivalent experience preferred.

Licenses / Certifications:

N/A

Other:

If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control. Ability to assess and solve customer problems by using excellent interpersonal skills, oral and written. Intermediate Computer skills. Medical terminology Knowledge of insurance requirements, plans, pre-certification requirements and contract benefits, ICD 10 and CPT codes. Must possess a working clinical knowledge of commonly used healthcare concepts, practices, and procedures with particular emphasis on Outpatient Services.