Authorization Specialist

POSITION DESCRIPTION:

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

ESSENTIAL JOB FUNCTIONS: 

1. Reviews patient medical history to identify supporting documentation in the patient chart relevant to the medication, service or procedure.
2. Contacts insurance companies via appropriate methods and obtains pre-certifications and authorizations.
3. Obtains urgent authorizations same day, next day.
4. Verifies correct procedural and diagnostic codes and insurance verification.
5. Monitors in-basket, email and fax server if applicable. Follows up on correspondence timely and accurately.
6. Monitors authorizations or denials and follows up, as necessary.
7. 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.
8. Communicates with the ordering provider for next steps, with practice support staff and representatives of insurance companies.
9. Generates authorization information for physicians, patients and health plans.
10. Acts as a liaison among providers, patients, staff, health plan administrators and Hospital representatives.
11. 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. 
12. 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.
13. 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.
14. Supports other offices, attends required meetings and training, and participates in committees as requested.
15. Participates in data collection and data review assignments as required.
16. Assists with special projects and assumes additional duties as assigned. Scans and files documents.

ORGANIZATIONAL EXPECTATIONS:

1. Creates a positive, professional, service-oriented work environment for staff, patients and family members by supporting the mission and values of both IHA and Trinity Health.
2. Must be able to work effectively as a member of the Specialty Service Center or Call Center team.
3. Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management.
4. Successfully completes IHA’s “The Customer” training and adheres to IHA’s standard of promptly providing a high level of service and respect to internal or external customers.
5. Maintains knowledge of and complies with IHA standards, policies and procedures.
6. Maintains complete knowledge of office services and in the use of all relevant office equipment, computer and manual systems.
7. Maintains strict patient and employee confidentiality in compliance with IHA and HIPAA guidelines.
8. Serves as a role model by demonstrating exceptional ability and willingness to take on new and additional responsibilities.  Embraces new ideas and respects cultural differences.
9. Uses resources efficiently.
10. If applicable, responsible for ongoing professional development – maintains appropriate licensure/certification and continuing education credentials, participates in available learning opportunities.

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):

1. Knowledge of medical terminology and procedures at the level needed to perform responsibilities.
2. Knowledge of the compliance aspects of clinical care and patient privacy and best practices in medical office operations.
3. Proficient knowledge of major health plans and insurance processes.
4. Excellent communication skills in both written and verbal forms, including proper phone etiquette, including ability to effectively explain relevant insurance information to patients and providers, as well as communicate with insurance plans and internal customers.  Ability to read, understand and respond to detailed written and oral instructions.
5. Proficient/knowledgeable in patient care procedures and organizational policies related to position responsibilities.
6. Service-oriented; responsive to customer needs and courteous in approach.
7. Proficiency in operating a standard desktop and Windows-based computer system including, but not limited to, electronic medical records (EMR), PowerChart, email, Microsoft Word/Excel/Outlook, e-learning, intranet and computer navigation. Ability to use other software as required while performing the essential functions of the job. 
8. Ability to perform mathematical calculations needed during the course of performing basic job duties.
9. Ability to work independently and collaboratively in a team-oriented environment; displays professional and friendly demeanor.
10. Ability to work effectively with various levels of organizational members and diverse populations including IHA staff, patients, providers, family members, vendors, outside customers and community groups.
11. Ability to cross-train in other areas of practice in order to achieve smooth flow of all operations.
12. Good organizational and time management skills to effectively juggle multiple priorities and time constraints and ever-changing medical situations.
13. Ability to exercise sound judgement and problem-solving skills.
14. Ability to handle patient and organizational information in a confidential manner.
15. Ability to travel to other office/practice sites and meeting and training locations.
16. Successful completion of IHA competency-based program within introductory and training period.

MINIMUM PHYSICAL EXPECTATIONS:

1. Physical activity that often requires keyboarding, filing and phone work.
2. Physical activity that often requires extensive time working on a computer.
3. Physical activity that sometimes requires walking, standing, bending, stooping, reaching and/or twisting.       
4. Physical activity that sometimes requires lifting, pushing and/or pulling under 30 lbs.
5. Specific vision abilities required include close vision, depth perception, peripheral vision and the ability to adjust and focus. 
6. Manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment.
7. Must hear and speak well enough to conduct business over the telephone or face to face for long periods of time in English.

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.