Authorization Specialist

The Authorization Specialist role is responsible for all administrative aspects of outpatient diagnostic testing and procedure benefit verification and authorization. This role will ensure patient’s insurance requirements for reimbursement before diagnostic testing or procedure. Obtains pre-authorizations for Physician Orders for diagnostic testing or procedure as required by the patient’s insurance carrier. Ensure the financial feasibility of treating each patient in our clinics by communicating and working closely with patients, physician, nurse and social worker. Work in specific areas of concern in the department on a project basis. Assist Patient Finance Manager in training staff, projects and implementations. Maintain in-depth knowledge of authorization process as well as reimbursement methodologies. Maintain knowledge of collection techniques and collection laws.

Responsibilities:

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  Obtains pre-authorizations for Physician Orders for diagnostic testing or procedure as required by the patient’s insurance carrier.

• Communicates with physician/clinical staff on reimbursement issues and/or pre-certification requirements by the patient’s insurance carriers.

• Ensures up-to-date documentation on patient’s accounts in Electronic Medical Record on authorization approvals and denials.

• Communicates with Insurance Authorization Coordinators the need for updated referrals.

• Communicates with front office manager and staff in the case of denials that will require rescheduling and/or peer-to-peer review by the ordering physician.

• Communicates with hospitals or other diagnostic facilities to correct any discrepancies.

• Contacts Insurance Authorization Coordinators to notify of termed insurances.

• Communicates as necessary and in a timely fashion with Front Office and imaging center staff with regards to the status of pending authorizations.

• Contacts Clinical Trial team to notify of denied scans for patients on study to verify coverage of scan by study.

• Keeps current on insurance carrier requirements for diagnostic testing and procedures.

• Follows policy and procedures outlined by management to ensure standardization of processes across the clinics.

• Additional responsibilities may be assigned to help drive our mission of improving the lives of everyone living with cancer.

• Lab Information System, Pharmacy Information System, Entire Chart/Electronic Medical Record (EMR), Electronic Billing System (EBS).

• Works denial worklist completing retro authorization request and or medically necessary appeals.

• Review payer guidelines for medically necessity guidelines including frequency and prior testing requirements.

Required Qualifications:

• High School diploma or equivalent.

• One year experience in a directly related role preferred, but not required.

• High School diploma or equivalent required.

• 1 year(s) of Prior Authorization experience.

• Medical insurance background required.

Essential Competencies:

• Attendance is an essential job function.

• Ability to work effectively with all levels of management and other colleagues

• Ability to demonstrate initiative and mature judgment.

• Ability to demonstrate high degree of professionalism and adaptability.

• Ability to demonstrate proficiency in the use of end-user computer applications (MS work, Excel, Outlook), database and patient scheduling and other medical information systems.

• Ability to demonstrate strong customer service delivery skills.

• Ability to utilize websites, portal and electronic options when available to increase efficiency

• Ability to follow oral and written instructions.

• Ability to recognize and solve problems using creative thinking skills, hands on problem solving skills and the ability to analyze and respond to data.

• Skilled at effective verbal and written communications, including active listening skills and skill in presenting findings and recommendations.

• Skilled at Multi-tasking, organizational skills and superb attention to detail.

• Working knowledge of Hospice and other payer requirements.

• Knowledge of clinic office procedures, medical practice and medical terminology.

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