Authorization Specialist

GENERAL SUMMARY:

Reviews all procedures both scheduled and pre-registered with the applicable insurance policies to ensure all the payer required guidelines are met prior to the service being rendered to ensure maximum reimbursement. Responsible for communication with all offices and appropriate internal personnel regarding the scheduling of services and needed prior authorizations. Validates that the patient's presenting problems/needs align with clinical protocols and indication for procedure(s) ordered and collaborated with the ordering provider for this information if needed.

Responsible for any required retro-authorizations as well as coordinating any peer-to-peer meetings between the payer and the performing provider or assigned advanced practice provider. This position will collaborate in an interdisciplinary manner to optimize patient care, reimbursement, and regulatory compliance

PRINCIPAL JOB FUNCTIONS:

• Commits to the mission, vision, beliefs and consistently demonstrates our core values.
• Participates in meetings, committees and lean projects as assigned.
• Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
• Performs service excellence must-haves to achieve an excellent patient/customer experience.
• Uses quality improvement processes, programs or outcome to help improve department operations.
• Serves as work resource and liaison to hospital departments, physician offices, and patients for pre-service authorization.
• Works closely with the Revenue Cycle team (Coders and Billers) to ensure accurate procedure and diagnosis codes are utilized in the pre-authorization process.
• Ensures that pre-certification and/or authorization and referral requirements have been completed by placing phone calls to insurance companies, physician offices, patients, and utilizing web based applications and/or internet resources; obtains clinical information from physician offices; contact coding staff to obtain CPT and/or ICD-10 codes. Documents authorization number/code in the appropriate tracking system.
• Explains notice of non-coverage or offers to re-schedule elective tests and procedures, when patient's pre-authorization is not obtained; notifies patient and physician of outcome.
• Assists in appeals to insurance company when denial is received and conducts follow-up as appropriate.
• Coordinates obtaining waiver of liability when third party payers deny coverage or services that are non-covered.
• Updates the applicable computer systems with the authorization numbers and other applicable information.
• Maintains accurate payer website information and logins to ensure most current information is obtained for the necessary authorization requirements.
• Stays current with pre-authorization guidelines specific to payers and informs staff and administration as necessary.
• Maintains productivity and quality standards as defined through the organizational and departmental goals and objectives
• Performs other related projects and duties as assigned.

EDUCATION AND EXPERIENCE:

High School Diploma or equivalent required. Associates in Health Information, Medical Assisting, or completion of a Coding Certification course preferred. Registered Health Information Technician (RHIT), Certified Medical Assistant (CMA), or other clinical background preferred. Minimum of one (1) year relevant work experience in a medical clinic or billing office required. Knowledge of ICD-10/CPT coding preferred.