Authorization Specialist

About the role

The Authorization Specialist plays an intricate role in procuring payment for outpatient services by financially clearing accounts—including specialty units, invasive interventional, clinical procedures, and diagnostic testing—within Good Samaritan, Bon Secours, and St. Anthony Community Hospitals. Each case is assessed for clinical‑related concerns and resolved prior to patients presenting to the hospital to ensure a speedy check‑in and avoid a delay in patient care. The specialist acts as a liaison between physicians, the OR, frontline registration, specialty areas, and all diagnostic departments, providing excellent customer service while adhering to departmental productivity performance measures.

Responsibilities

• Utilize multiple patient information systems to obtain/secure authorization, verify benefits, and perform medical necessity checks.
• Obtain, validate, and interpret clinical documentation—including orders, H&P, physician progress notes, lab results, and radiology results—to ensure all guidelines are met.
• Perform registration functions and advise front‑line registration on required information to complete the check‑in process.
• Assist in resolution of denials and billing issues through extensive chart research, retro authorizations, coding, and documentation.
• Maintain and resolve appointed Account and Patient Work Queues; adjust accounts and insurances as necessary using hospital billing applications.
• Discuss patient liability under stressful conditions while maintaining a positive patient experience.
• Document all financials, payer requirements, and clinical documentation in Cerner, and provide alerts for front‑line registrars.
• Collect demographic and insurance data, ensuring accuracy and completeness; validate that the correct insurance payer is loaded in the encounter.
• Utilize insurance grids to load correct insurance and schedule or cancel procedures within the Cadence platform.
• Perform eligibility checks on insurance payers using websites, telephone, and RTE; run RTE for every account on the 1st and 15th of each month.
• Understand resource availability, equipment limitations, and physician suspension; complete and follow up on the Scheduled Orders report.
• Communicate cooperatively and constructively with patients, supervisors, families, co‑workers, administration, billing, denials, customer service, clinical departments, providers, community agencies, referral sources, and other health‑team members.
• Assist and educate team members when necessary; handle difficult or upset callers with professionalism.
• Maintain a high level of accuracy and attention to detail; adhere to new functions and processes to ensure account completion.
• Attend ongoing system training and participate in department in‑services to increase knowledge of procedures, resources, and departments.
• Adhere to current processes and workflows to avoid cancellations and denials.
• Perform other duties as assigned.

Qualifications

• 3–5 years of experience in a pre‑authorization specialty preferred; candidates with two years of centralized scheduling experience also considered.
• Knowledge of insurance requirements, plans, pre‑certification requirements, contract benefits, ICD‑10 and CPT codes.
• Proficiency in medical terminology and interpretation of physician orders and clinical documentation.
• Working clinical knowledge of outpatient services and commonly used healthcare concepts, practices, and procedures.
• Strong interpersonal, oral, and written communication skills for serving a variety of patients and physician practices.
• Experience in conflict management and ability to assess and solve customer problems.
• Intermediate computer skills; experience with Cerner, Cadence, and insurance eligibility systems.
• Associate degree or equivalent combination of experience and training.

Other Information

The individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Employees are required to exercise universal precautions, use personal protective equipment, and follow infection‑control policies.