Authorization Specialist

Authorization Specialist

POSITION DESCRIPTION :

This position is responsible for all aspects of the authorization / pre-certification or referral process.

ESSENTIAL JOB FUNCTIONS :

• Reviews patient medical history to identify supporting documentation in the patient chart relevant to the medication, service or procedure.
• Contacts insurance companies via appropriate methods and obtains pre-certifications and authorizations.
• Obtains urgent authorizations same day, next day.
• Verifies correct procedural and diagnostic codes and insurance verification.
• Monitors in-basket, email and fax server if applicable. Follows up on correspondence timely and accurately.
• Monitors authorizations or denials and follows up, as necessary.
• Updates information in patient medical record (EMR) with approval or declination information; follows up with Primary Care Physician as to status and / or issues with prior authorization.
• Communicates with the ordering provider for next steps, with practice support staff and representatives of insurance companies.
• Generates authorization information for physicians, patients and health plans.
• Acts as a liaison among providers, patients, staff, health plan administrators and Hospital representatives.
• Works the follow up work queue for Retro Authorization denials by either correcting the PCP or obtaining a retrospective authorization and routing the claim back to Denials Management for rebilling.
• Communicates referral status to patients, staff and physicians; ensures that referrals have been processed accurately and in a timely manner to coincide with patient treatment plan.
• Relays clinical information to health plan case managers for special procedure pre-certification and out-of-plan or out-of-network referrals; monitors authorizations or denials and follows up, as necessary.
• Supports other offices, attends required meetings and training, and participates in committees as requested.
• Participates in data collection and data review assignments as required.
• Assists with special projects and assumes additional duties as assigned. Scans and files documents.

ORGANIZATIONAL EXPECTATIONS :

MEASURED BY :

Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position.

ESSENTIAL QUALIFICATIONS :

EDUCATION : High School Diploma. Associate’s Degree in healthcare or related field and specialized training or equivalent combination of education and experience, preferred.

CREDENTIALS / LICENSURE : None

MINIMUM EXPERIENCE : 1-2 years’ experience with insurance referrals, prior authorization or other relevant medical office experience.

POSITION REQUIREMENTS (ABILITIES & SKILLS) :

MINIMUM PHYSICAL EXPECTATIONS :

MINIMUM ENVIRONMENTAL EXPECTATIONS :

This job operates in a typical office environment with some exposure to contagious diseases / viruses. It requires significant interaction with people (many of whom are scared, hurt and / or ill) which can be stressful and result in competing priorities.

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