Authorization Specialist

INTERNAL ONLY for current Crete Area Medical Center employees.

ABOUT THE ROLE:

Reviews all procedures, both scheduled and pre-registered, with the applicable insurance policies to ensure all the payer required guidelines are met prior to the service being rendered to ensure maximum reimbursement. Responsible for communication with all offices and appropriate internal personnel regarding the scheduling of services and needed prior authorizations. Validates that the patient's presenting problems/needs align with clinical protocols and indication for procedure(s) ordered and collaborates with the ordering provider for this information if needed.

Responsible for any required retro-authorizations as well as coordinating any peer-to-peer meetings between the payer and the performing provider or assigned advanced practice provider. Collaborates in an interdisciplinary manner to optimize patient care, reimbursement, and regulatory compliance.

Responsible for, and is proficient in, all functions of the Patient Access Department, including pre-admitting, admitting, receptionist duties and scheduling of patients for hospital and clinic procedures and appointments. Must be able to perform all job duties and responsibilities in all facility areas that the Patient Access Department covers to include preparing and providing patients with an estimate, if one is warranted, for their expected services. Collects and/or counsels on expected payment due.

YOUR ROLE WOULD ENCOMPASS:

• Commits to the mission, vision, beliefs and consistently demonstrates our core values.
• Performs service excellence must-haves to achieve an excellent patient/customer experience.
• Uses quality improvement processes, programs or outcome to help improve department operations.
• Serves as work resource and liaison to hospital departments, physician offices, and patients for pre-service authorization.
• Works closely with the Revenue Cycle team (Coders and Billers) to ensure accurate procedure and diagnosis codes are being utilized in the pre-authorization process.
• Ensures that pre-certification and/or authorization and referral requirements have been completed by placing phone calls to insurance companies, physician offices, patients, and utilizing web-based applications and/or internet resources; obtains clinical information from physician offices; contacts coding staff to obtain CPT and/or ICD-10 codes. Documents authorization number/code in the appropriate tracking system.
• Explains notice of non-coverage or offers to re-schedule elective tests and procedures when patient's pre-authorization is not obtained; notifies patient and physician of outcome.
• Assists in appeals to insurance company when denial is received and conducts follow-up as appropriate.
• Coordinates obtaining waiver of liability when third party payers deny coverage or services that are non-covered.
• Updates the applicable computer systems with the authorization numbers and other applicable information.
• Maintains accurate payer website information and logins to ensure most current information is obtained for the necessary authorization requirements.
• Stays current with pre-authorization guidelines specific to payers and informs staff and administration, as necessary.
• Maintains productivity and quality standards as defined through the organizational and departmental goals and objectives.
• Performs services related to Patient Access Department including but not limited to receptionist, switchboard, scheduling admits and check in/check out of patients.
• Performs opening and closing tasks of admissions area.
• Performs pre-admissions, admission and dismissal functions for all hospital and clinic areas including - Acute, Emergency, Surgery, Outpatient, Cardiac Rehab, Physical Therapy and Physician's Clinic.
• Registers and checks in patients as they arrive for services. Obtains, scans and enters data into the computer system including demographic information, insurance coverage and all forms required for the visit.
• Prepares and provides patients with an estimate, if one is warranted, for their expected services. Collects and/or counsels on expected payment due.
• Gathers, verifies and processes authorizations and pre-certifications by collaborating closely with providers, patients and payers as needed.
• Keeps all admissions, forms, and computer information up to date.
• Directs patients and visitors and gives them appropriate information.
• Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
• Participates in meetings, committees and lean projects as assigned.

YOUR EXPERIENCE INCLUDES (PROVEN PERFORMANCE IN):

• High School Diploma or equivalent - required.
• Associates in Health Information, Medical Assisting, or completion of a Coding Certification course - preferred.
• Registered Health Information Technician (RHIT), Certified Medical Assistant (CMA), or other clinical background - preferred.
• Minimum of one (1) year relevant work experience in a medical clinic or billing setting - required.
• Knowledge of ICD-10/CPT coding - preferred.