Radiology Authorization & Eligibility Specialist

Principal Duties And Responsibilities

• Verifies patient’s insurance eligibility, benefits, and authorization requirements for specific imaging procedures.
• Collaborates with members of all care teams to ensure effective communication regarding all commercial insurance issues.
• Facilitates problem-solving with clinical departments, providers, referral sources, insurance companies, and authorization staff.
• Accurately obtains insurance authorization for patients.
• Ensures authorization is provided in a timely manner.
• Comprehensively documents insurance discussions in the Epic referral to communicate up to date details with colleagues.
• Collaborates with Oncology staff, Pharmacy Team, RN Navigators, and Laboratory services to minimize denials and obtain authorizations in a timely manner.
• Prioritizes authorization requests according to medical urgency.
• Reviews medical records for submission to insurances, abstracting information from patient medical records pertaining to patient treatments, procedures, and guidelines as required.
• Reviews patient treatment plan including frequency and dosage prior to treatment and reviews the applicable payer reimbursement criteria to ensure that the specific payer’s medical necessity criteria are met.
• Tracks authorization status and follows up on pending or denied requests.
• Maintains a 4-day window to ensure unauthorized procedures are removed from the schedule.
• Communicates any changes in schedule to patient as well as authorization status and any out-of-pocket expenses to the patient in a timely manner.
• Quickly and courteously responds to concerns from patients, staff, and others involved in patient care while maintaining a respectful demeanor.
• Conducts outbound calls to patients and providers for patient support.
• Accepts inbound calls from patients and providers to provide support.
• Follows departmental standards to document all calls.
• Promptly identifies and resolves all operational issues affecting insurance verification and authorization to ensure a smooth workflow from order creation to billing.
• Works closely with nursing staff to ensure that patients are scheduled in a timely manner.
• Maintains internal processes to comprehensively track authorization requirements by patient and follows up as appropriate utilizing established Epic work queues.
• Assists with appeals and denial management as necessary.
• Maintains current knowledge of payers’ requirements for pre-authorizations, certifications and verifications.
• Assists with training new hires in authorizations.
• May perform other duties as assigned.

Skills

• Thorough knowledge of authorization processes
• Basic understanding of insurance policies/procedures
• Detail oriented with excellent telephone, analytical, organization and time management skills
• Collaboration with clinical staff regarding challenging patient needs
• Basic understanding of complete revenue cycle
• Knowledge of ICD-10 and CPT coding practices
• Strong computer skills, including EMR knowledge and Microsoft Office
• Skill in data analysis and interpretation
• Strong interpersonal skills
• Ability to work in a fast-paced environment and meet frequent deadlines
• Ability and initiative to plan for and complete daily activities with minimal direction
• Ability to assist with process and procedure development

Education

• High School
• 2 years of progressive insurance authorization experience preferred
• Epic experience desired