Role Description
The Authorization Specialist is responsible for obtaining authorizations for surgical procedures, diagnostic testing, medications, DME, outgoing referrals, and other services as part of the daily operations of the Revenue Cycle Department. Authorization Specialists must have a keen understanding of medical insurance and the clinical policies that determine the authorization protocols for each health plan.
Essential Job Functions:
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Identifies all appointments and procedures for assigned departments that require authorization by monitoring the schedules, system reports, and dashboards.
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Identifies the referral and authorization requirements of the patients’ insurance plans by using various online resources according to department workflows.
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Demonstrates knowledge of insurance carrier guidelines, clinical policies, and state guidelines pertaining to referrals and prior authorization.
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Verifies insurance eligibility and benefits, and updates the patient’s insurance information as necessary.
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Completes referrals and prior authorizations in a timely manner according to department guidelines and workflows.
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Communicates clearly and effectively with patients, physicians, office staff, and manager to resolve issues that may result in a denied or delayed authorization request.
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Demonstrates complete system knowledge, ability to run reports, document and manage referrals and authorizations, move correspondence, resolve eligibility and authorization holds, and other system tasks within the user’s security access.
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Demonstrates the ability to request, prepare, and recognize the documentation required to support the medical necessity for the service being authorized.
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Provides the supervisor and manager with immediate feedback on issues affecting workflow, reimbursement, and customer service.
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Ensures that appropriate and accurate information is entered in the patient account.
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Responds timely and collaborates effectively with the Reimbursement Department teams to limit denials and ensure proper reimbursement.
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Collaborates with team members to meet department deadlines and benchmarks.
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Demonstrates the ability to use the electronic tools and systems available to organize and process the daily work.
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Anticipates and performs necessary job duties.
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Maintains patient confidentiality.
General Job Functions:
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Expert in selecting the correct insurance package in Epic.
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Updates authorizations and claims to reflect the new insurance package.
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Expert in sorting work queues and reports to identify and process the daily work (Manage Schedules - Inbound Referral Report - Outgoing Referrals).
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Moves correspondence from the dashboard to the patient’s account.
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Expert in generally accepted insurance benefit terms and processes.
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Expert in Communication (Case and authorization notation - Physician and Practice location staff – Peers - Supervisor/Manager – Payers).
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Expert in requesting and preparation of supporting documentation such as medical records, dictation, and orders.
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Expert in investigation of authorization denials and appeals (Insurance – Patient).
Qualifications
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High School Graduate/GED Required.
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Vocational / Technical School / Diploma Program Preferred.
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2-4 years of related experience Preferred.
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Experience with Standard Office Equipment (Phone, Fax, Copy Machine, Scanner, Email/Voice Mail) Preferred.
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Experience Standard Office Technology in a Windows-based environment & Microsoft Office Suite Required.
Benefits
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Participation in VillageMD’s benefit platform includes Medical, Dental, Life, Disability, Vision, FSA coverages, and a 401k savings plan.
Equal Opportunity Employer
Our Company provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to, and does not discriminate on the basis of, race, color, religion, creed, gender/sex, sexual orientation, gender identity and expression (including transgender status), national origin, ancestry, citizenship status, age, disability, genetic information, marital status, pregnancy, military status, veteran status, or any other characteristic protected by applicable federal, state, and local laws.
Safety Disclaimer
Our Company cares about the safety of our employees and applicants. Our Company does not use chat rooms for job searches or communications. Our Company will never request personal information via informal chat platforms or unsecure email. Our Company will never ask for money or an exchange of money, banking or other personal information prior to the in-person interview. Be aware of potential scams while job seeking. Interviews are conducted at select Our Company locations during regular business hours only.
