Insurance Authorization Specialist

JOB SUMMARYActs as a liaison with all insurance providers including commercial, managed care, and governmental plansGathers and submits patient information to secure prior authorizations for inpatient IRF and LTACH admissionsGathers and transmits required documentation to the Medicare Administrative Contractor as required by CMS in the setting of demonstration projects and auditsAssures accuracy of authorizations including program identifiers and level of careCommunicates the need for peer-to-peer discussions and / or member appeals as necessary in the case of denied authorization requestsResearches authorization related denials, determines cause and resolution, and communicates with hospital billing for corrected claim submissionActs as a patient advocate between the patient and their insurance planProvide support with verification of patient benefits and eligibility as needed

ESSENTIAL FUNCTIONSPATIENT / CUSTOMER

Essential Accountabilities

Maintain compliance with HIPAA regulations.Act as a patient advocate between the patient and the insurance plan.Develop and maintain strong collaborative relationships with insurance providers.

Recognize time sensitive nature of obtaining prior authorizations.Accurate and timely communication of authorization status to Clinical Liaison, Admission, and Case Management teams.

Conduct real-time and retrospective chart audits for CMS compliance.Contributes to a positive work environment and to the overall efforts of the Patient Access and Case Management teams.

Non-Essential Accountabilities

Perform other duties in the scope of payer relations as assigned.

PATIENT / EMPLOYEE SAFETY ACCOUNTABILITIES

Participates in Entity and Department wide initiatives for Patient / Employee safety.Demonstrates an awareness of patient / employee safety when carrying out daily responsibilities.

Regular validation of competencies as related to tasks required for the position.

OPERATIONS

Essential Accountabilities

Direct communication with Clinical Liaison and Admission teams to determine need for patient prior authorization via daily meetings, email, text and phone.

Obtain necessary demographic and clinical information to support prior authorization via PennChart, patient records, and with direct communication with Clinical Liaison and Admission team.

Maintain contact list for prior authorization and utilization management representatives with contracted insurance providers.

Secure prior authorizations for patient admissions via insurance provider portal and phone, or as directed by insurance provider.

Communicate status of authorization to Clinical Liaison, Admission, and Case Management teams in a timely manner.Communicate the need for peer-to-peer discussions and / or member appeals as necessary in the case of denied authorization requests.

Investigate claim denials for authorization related issues, determine cause, and contact insurance provider for resolution.

Conduct real-time and retrospective chart audits as needed to determine compliance with payer regulations.Verify patients' insurance benefits and eligibility for services via insurance provider portal and phone, or as directed by insurance provider, as needed.

Remains current with Managed Care and Payer Relations updates.Remains current with CMS updates affecting the IRF and LTACH programs.

Partner with Penn Medicine and GSRN Managed Care teams to develop Single Payor Agreements (SPAs) as needed.Verify prior authorizations are provided with the correct NPI and program identifiers for the IRF and LTACH programs.

Accurately record authorizations and related notes in the Electronic Medical Record for billing procedures.

Non-essential Accountabilities

Promotes available services of the GSPP IRF and LTACH.Participates in GSPP unit-based committees as needed.

QUALIFICATIONS : To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.

The requirements listed below are representative of the knowledge, skill, and / or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EducationHigh School Diploma requiredAssociate's Degree preferred

Work Experience1 -2 years in health insurance authorization or verification process; hospital experience preferred

Licenses / CertificationsN / A