Authorization Specialist Associate -Remote

About the role

Authorization & Cost Estimate Specialists collect necessary insurance benefit and clinical information to authorize services or provide accurate cost estimates based on the patient’s insurance benefits. This is a remote position requiring onsite attendance quarterly or as needed for training.

The Authorization Specialist must have clinical knowledge of services to communicate appropriate information to insurance companies, ensuring services are rendered at the correct level of care. Reimbursement depends on accurate insurance benefit verification and meeting authorization requirements.

The Cost Estimate Specialist determines service costs by applying patient benefits and coverage information through IT applications, ensuring patients understand their financial responsibilities. This role operates in a dynamic environment with frequent changes in insurance plans, benefits, and coverage structures, requiring quick turnaround to avoid treatment delays.

This team serves as a point of contact for insurance-related questions and issues within the organization.

Responsibilities

• Authorization:
  • Utilizes online systems, phone communication, and other resources to verify eligibility, benefits, and coverage; secures pre-authorizations and determines patient liabilities within required timeframes.
  • Verifies medical necessity in accordance with CMS standards and communicates coverage/eligibility information to patients.
  • Coordinates benefits by determining primary, secondary, and tertiary liability when needed.
  • Obtains pre-certifications and pre-authorizations from third-party payers according to their requirements.
  • Alerts physician offices to issues with verifying insurance or obtaining pre-authorizations.
  • Demonstrates understanding of insurance terminology (e.g., co-payments, deductibles, allowances) and analyzes information to determine patients’ out-of-pocket liabilities.
  • Connects patients with financial counselors for further explanation or education on payment plans or financial assistance; may conduct basic financial counseling.
• Cost Estimates:
  • Utilizes online systems and phone communication to verify eligibility and create cost estimates for scheduled services based on patient benefits.
  • Communicates liabilities directly to patients and educates them on key insurance terms and rules, often handling complex plans (e.g., workers’ compensation).
  • Documents cost estimates in the EHR for collection prior to or on the date of service.
  • Notifies physician offices when patients with out-of-network or limited benefit plans are scheduled.
• Communication:
  • Communicates with patients, physicians, clinicians, front-end staff, or translators to obtain missing demographic or insurance information.
  • Maintains excellent relationships with physician offices, insurance companies, and other hospital departments.

Requirements

• High School Diploma or GED required; Associate or bachelor’s degree in healthcare administration or related field preferred.
• One to two years of registration or insurance verification-related experience preferred.

Skills

• Knowledge of EHR programs (e.g., Epic), medical terminology, insurance plans, and benefits.
• Proficient critical thinking, detail-oriented, and problem-solving skills.
• Excellent communication (written and verbal) and interpersonal skills.
• Exceptional time management, conflict resolution, and multitasking abilities.
• Ability to work well in a team environment and independently.
• Proficient in Microsoft Office products.
• Exhibits professionalism, trustworthiness, honesty, and integrity.
• Customer service and/or call center experience preferred.