The Specialist-Authorization is responsible for initiating a Pre-Authorization request to the payer for the claims that require approval. This position requires communication with payers, patients, physician offices, and hospital clinical staff. This position is primarily responsible for pre-certifying procedures ordered by physicians. The Specialist-Authorization will also be responsible for monitoring appropriateness and medical necessity, and providing necessary information for authorization and continued visits. This individual will confirm pre-certifications that have been obtained or will obtain pre-certifications if needed.
- Serve as primary contact for all SEHA Business Entity prior authorization requirements
- Serve as the primary resource for SEHA Business Entity reading of prior authorization process and requirements;
- Collect clinical information regarding services to be rendered;
- Contacts insurance companies by phone, fax, or online portal to obtain insurance benefits, eligibility, and authorization information;
- Updates systems with accurate information obtained;
- Responsible for communicating to service line partners of situations where rescheduling is necessary, due to lack of authorization or limited benefits and is approved by clinical personnel;
- Works with inpatient accounts for authorization and held responsible for timely notification to payers of the patient’s admission to the facility to protect financial standing;
- Uses utmost caution that obtained benefits, authorizations, and pre-certifications are accurate according to the actual test and procedure or registration being performed;
- Ensures all benefits, authorizations, pre-certifications, and financial obligations of patients, are documented on account memos, clearly, accurately, precise, and detailed to ensure expeditious processing of patient accounts;
- May contact physicians, Case Management, and Utilization Review to facilitate the sending of clinical information in support of the authorization to the payer, as assigned;
- Monitors team mailbox, e-mail inbox, faxes, and phone calls responding to all related Pre-Access account issues, within defined time frames;
- Contact the payer to obtain prior authorization. Gather additional clinical and or coding information, as necessary, in order to obtain prior authorization;
- Provide standardized documentation within the system to identify prior authorization and the criteria surrounding such authorization;
- Stay informed and research information regarding insurance criteria for prior authorization;
- Serve as the primary resource to patients regarding the prior authorization process
Required:
- 12 years of Revenue Cycle Experience in lieu of degree.
- Healthcare Certification (CRCR and/or CHAM)
- Extensive knowledge of healthcare revenue cycle systems;
- Minimum two (0-2) years of medical insurance verification and authorization required;
- Billing and coding experience preferred;
- Minimum of (0-2) years documented and recent experience in a medical facility setting where the use of the electronic system for complex coding, insurance issues, pre-certification, and outbound referral management is evident;
- Experience, testing, or academic coursework completion of CPT, ICD-10, HCPCS, LMRPs, and similar coding/guidelines;
- Experience with third-party payer requirements, contracts, authorization, and payment practices;
- Understanding of insurance requirements for prior authorization;
- Knowledge of registration, verification, pre-certification, and scheduling procedures;
- Understanding of payer processes (website, fax, contact number) to submit appropriate clinical documentation;
- Proficient knowledge of Microsoft Office and Outlook;
- Proficient knowledge of Medical Terminology and Medical Coding;
- Understanding of insurance billing procedures and practices;
- 1-3 years of prior authorization experience in a large healthcare, multi-integrated network, or third-party medical billing environment;
- Knowledge of ICD-10 and CPT-4;
- Experience with insurance terminology required.
