Authorization & Clearance Specialist; Days ; Jackson Main

Authorization & Clearance Specialist plays a critical role in ensuring that medical services provided to patients are covered by the patient's insurance providers. They are responsible for obtaining pre-authorizations, initiating authorizations, extending concurrent authorization, verifying insurance coverage for medical procedures, treatments, hospital stays, initiating retroactive authorization modifications, and discharge notifications as appropriate.

Responsibilities Identifies and confirms valid coverage for an episode of care and/or specific service: contacts insurance companies and/or reviews electronic response summary and coverage discovery information to ensure the appropriate coverage coordination are on the patient's record. Initiates authorization with patient insurance by submitting necessary clinical documentation, continues to follow up, obtain and validate authorization/referrals/notifications with appropriate CPT, ICD-10 codes, Tax ID and NPI #s within the appropriate timelines.

Works daily work queues according to department directives, to identify patients requiring authorization for services scheduled and non-scheduled appropriately prioritizing work assignments based on scheduled appointment date/time, medical severity, payer assignments, dollar value etc. Verifies that the services the patient is set to receive is a covered benefit, validates benefit package restrictions, and completes quality assurance checks on authorization patient type, facility, etc.

Understands patient deductibles, out of network referrals, out of pocket limitations, and lifetime/event caps on liability. Refers patients to appropriate Financial Counselor, Prior Authorization or Billing based on financial coverage, financial situation, employment status, liability and/or patient concern. Uses insurance discovery tools available to attempt to validate any and all insurance coverage, ensure correct insurance coordination of benefits are listed on patient's record, follows up with patient/next of kin/Social Work/Case Management in order to obtain insurance coverage information.

Verify all insurance and obtain pre-certification/authorization for services, as warranted, and notifying patient and referring physician in the event of failed eligibility and/or authorization. Follows up with and escalates as appropriate to physician's office/clinical teams/Case Management for any pending clinical documentation, including peer-to-peer requests. Diligently follows up on any pending authorizations to ensure information is processed with the insurance payer within appropriate timelines.

Works directly with JHS medical services to ensure procedures, diagnoses, level of care, are sufficient for each case by following CMS and payer guidelines and communicating with medical team for corrections. Maintain knowledge base of all programs offered by JHS for Charity and Financial Assistance and the requirements to qualify, with the process for Charity Care clearance of scheduled procedures and coverage. Calculates patients' financial responsibility based on patient benefits using the estimator tools and includes communication with the patients on the out of pocket due at service.

Coordinate Self-pay Package pricing by utilizing tools available and escalating to Managed Care team to obtain appropriate package price amounts not found on list or complex contracts. Receives and processes all patient payments in accordance with JHS Collections Policy and Procedure, issues receipt and maintains the integrity of all payments. Scans/uploads all required documents into the appropriate folder in the documenting imagining system in a timely manner to assure maximum reimbursement and compliance.

Assist in supporting go lives of new systems and different department initiatives, including onboarding and training team members. Cross-trained in multiple areas/service lines/payers to substitute all staff positions as needed. Demonstrates behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise).

Performs other related job duties as assigned. Experience Generally requires 0 to 3 years of related experience. Financial clearance experience is strongly preferred.

Education High school diploma is required. Bachelor's degree in related field is strongly preferred. Skill Ability to analyze, organize and prioritize work accurately while meeting multiple deadlines.

Ability to communicate effectively in both oral and written form. Ability to handle difficult and stressful situations with critical thinking and professional composure. Ability to understand and follow instructions.

Ability to exercise sound and independent judgment. Knowledge and skill in use of job appropriate technology and software applications. Credentials Valid license or certification is required as needed, based on the job or specialty.

Unit Specific Credential Working Conditions Physical Requirements - Job function is sedentary in nature and requires sitting for extended periods of time. Function may require frequent standing or walking. Must be able to lift or carry objects weighing up to 20 pounds.

Jobs in this group are required to have close visual acuity to perform activities such as: extended use of computers, preparing and analyzing data and analytics, and other components of a typical office environment. Additional information and provision requests for reasonable accommodation will be provided by the home unit/department in collaboration with the Reasonable Accommodations Committee (RAC). Environmental Conditions - Jobs in this group are required to function in a fast paced environment with occasional high pressure or emergent and stressful situations.

Frequent interaction with a diverse population including team members, providers, patients, insurance companies and other members of the public. Function is subject to inside environmental conditions, with occasional outdoor exposures. Possible exposure to various environments such as: communicable diseases, toxic substances, medicinal preparations and other conditions common to a hospital and medical office environment.

May wear Personal Protective Equipment (PPE) such as gloves or a mask when exposed to hospital environment outside of office. Reasonable accommodations can be made to enable people with disabilities to perform the described

. Additional information and provision requests for reasonable accommodation will be provided by the home unit/department in collaboration with the Reasonable Accommodations Committee (RAC).

Day Job