The Authorization Specialist plays an intricate role in procuring payment for outpatient services by financially clearing accounts including specialty units, invasive interventional, clinical procedures and diagnostic testing within Good Samaritan, Bon Secours and St Anthony Community Hospitals. 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 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.
Utilize multiple patient information related systems to obtain/ secure authorization, verify benefits, perform medical necessity checks. Obtain, validate and interpret clinical documentation including orders, H&P, physician progress notes, review lab results, radiology results, assuring all guidelines are met. Perform registration functions.
Assists in resolution of denials and billing issues, through extensive research of patient’s 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. Discuss patient liability under stressful conditions while maintaining a positive patient experience.
Advises front line registration what is needed to complete the check in process, Document in Cerner all financials, payer requirements, clinical documentation and any assistance or alert for the front-line registrar. Collects demographic and insurance data when applicable ensuring accuracy and completeness. Validate the correct insurance payer is loaded in the encounter.
Utilize insurance grids to load correct insurance. Schedule, cancel procedures within the cadence platform. 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. RTE runs for every account the first and 15th of every month. Understands resource availability, equipment limitations, and physician suspension.
Complete and follow up on the Scheduled orders report. 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. Assist and help educate all members of the team when necessary.
Handles difficult or upset callers with the utmost professionalism and customer service. Maintains a high level of accuracy and attention to detail. Will adhere to new functions and processes implemented to ensure accuracy and completion of all accounts.
Attends on-going system training and participates in department in-services to increase knowledge of procedures, resources and departments. Adhere to current process and workflows to avoid cancelations and denials. Performs other duties as assigned.
Qualifications/Requirements: Experience. Knowledge of insurance requirements, plans, pre-certification requirements and contract benefits, ICD 10 and CPT codes. Medical terminology Interpretation of physician orders and clinical documentation. 3-5 years of experience in a pre –authorization specialty preferred.
Consideration of candidates with two years of Centralized Scheduling experience. Ability to assess and solve customer problems by using excellent interpersonal skills, oral and written. Communication skills serving a variety of patients and physician practices.
Scheduling experience, preps, medication holds and order interpretation. Must possess a working clinical knowledge of commonly used healthcare concepts, practices, and procedures with particular emphasis on Outpatient Services. Requires experience in utilization of skills specifically related to conflict management.
Intermediate Computer skills.
Requires an associate degree or the equivalent combination of experience and training. Licenses /
N/A Other: 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 of personal protective equipment and devices, and learn the policies concerning infection control.