Authorization Specialist

Job Summary

The Authorization Specialist is responsible for ensuring that payers are prepared to reimburse Riverview Health for scheduled services in accordance with the payer-provider contract. The Specialist contacts payers to request service authorization and may collect clinical, financial and/or demographic information from clinics, hospital departments and/or patients as needed.

Job Responsibilities

• Verifies patients’ insurance and benefits information
• OBTAINS PRIOR AUTHORIZATIONS FROM THIRD-PARTY PAYERS IN ACCORDANCE WITH PAUSERQUIREMENTS
• IDENTIFIES PATIENTS WHO WILL NEED TO RECEIVE MEDICARE ADVANCE BENEFICIARY NOTICES OF NONCOVERAGE (ABNS)
• CONTACTS PATIENTS TO GATHER DEMOGRAPHIC AND INSURANCE INFORMATION AS NEEDED, AND UPDATES PATIENT INFORMATION WITHIN THE EMR AS NECESSARY
• WORKS WITH OTHER DEPARTMENTS TO GATHER THE CLINICAL INFORMATION REQUIRED BY THE PAUSER TO AUTHORIZATION SERVICES
• MANTAINS ACCURATE RECORDS OF AUTHORIZATIONS WITHIN EMR
• DEVELOPS PRICE ESTIMATES FOR PATIENT OUT-OF-POCKET RESPONSIBILITY
• REFERS ACCOUNTS TO FINANCIAL COUNSELING AS NEEDED IF AUTHORIZATION IS NOT OBTAINED
• WORKS WITH BUSINESS OFFICE STAFF TO SUPPORT APPEAL EFFORTS FOR AUTHORIZATION-RELATED DENIALS
• REVIEW SURGERY SCHEDULES TO ENSURE MEDICARE PATIENTS WITH IP-ONLY PROCEDURES HAVE THE APPROPRIATE AUTHORIZATION AND ORDER
• COMPLIES WITH HIPAA REGULATIONS, AS WELL AS RIVERVILLE HEALTH POLICIES AND PROCEDURES REGARDING PATIENT PRIVACY AND CONFIDENTIALITY
• MANTAINS PROFESSIONAL TONE AT ALL TIMES WHEN COMMUNICATING WITH PATIENTS AND PAUSER REPRESENTATIVES
• CORRESPONDS RE-EDUCATION TO PRACTICES OR HOSPITAL DEPARTMENTS WHEN ORDERS ARE INCORRECT OR NOT SUPPORTED BY THE GIVEN DIAGNOSIS
• POLLS OTHER DUTIES AS REQUESTED

Education Requirements

• Minimum: Associate degree in healthcare or business administration and/or related coursework, or comparable experience
• Preferred: Experience in Epic

Experience Requirements

• Minimum: Two years of experience in a healthcare setting performing related tasks
• Preferred: Five years of experience in a healthcare setting performing related tasks

Licenses/Certifications

• None