Referral and Authorization Specialist - Practice Support

About the Role

Supports and is responsible for incorporating the Frederick Health (FH) mission, vision, core values, and customer service philosophy into job performance. Adheres to the FH Compliance Program, including following all regulatory requirements and the FH Standards of Behavior. Under the direction of the Patient Access and HIM Manager and Department Lead, this position handles patient insurance carrier referrals, insurance authorizations for in-house procedures/services, insurance eligibility, benefits, pre-determinations, and price estimations. These tasks must be completed prior to the delivery of ambulatory services. Responsible for verifying patient demographic and financial information for all insurances and self-pay accounts.

The primary function of the Referral Authorization Specialist is to provide premier customer service to internal and external customers in determining patient coverage, authorization needs, predetermination, and patient estimations for care, in compliance with the No Surprise Act.

Responsibilities

• Complete the pre-determination and authorization process prior to services being rendered.
• Demonstrate extensive knowledge of all areas of registration and scheduling, including on-site and outpatient services.
• Understand medical insurance guidelines and participation agreements.
• Serve as the primary resource for obtaining patients’ referrals.
• Obtain primary care physician approval for patients’ referrals as required by the insurer.
• Maintain a working knowledge of all insurance requirements related to referrals, authorizations, pre-determinations, and medical necessity.
• Calculate price estimations per payer fee schedule prior to services being rendered.
• Maintain updated knowledge of providers within the surrounding areas and insurance participation.
• Complete referrals for patients to participating providers within the appropriate network to maintain maximum financial incentives/reimbursement from payers as directed by the provider.
• Assist providers and clinical staff in identifying the appropriate network/healthcare provider to use as a referral.
• Maintain knowledge of organizational quality metrics and goals.
• Utilize online insurance eligibility verification systems.
• Collaborate with designated clinical contacts regarding encounters that require escalation for peer-to-peer review.
• Facilitate submission of clean claims and reduction in payer denials by adhering to organizational and departmental policies and procedures to maintain productivity and quality goals.
• Answer incoming phone inquiries related to referrals, pre-authorizations, and medical necessity.
• Review statistical data from Cisco Finesse to ensure time efficiency on calls and complete self-assessments, as well as review assessments on calls reviewed by management.
• Offer to enroll patients in the patient portal when non-enrolled.
• Perform all other duties as assigned.

Requirements

• Attention to detail, with the ability to analyze and determine the type of data needed to complete various types of patient registration functions.
• Maintain a working knowledge of all insurance requirements for authorizations, referrals, and price estimates.
• Demonstrate ability to manage time, deadlines, multiple requests, and priorities, maintain productivity, and exercise good judgment with minimal supervision.
• Clinical knowledge, including medical terminology, medications, procedures/radiology, and surgeries from various medical specialty services.
• Ability to apply policies and procedures regarding data security and patient confidentiality (HIPAA) to prevent inappropriate release of patient information.
• Proficiency in computer software such as Microsoft Word, Microsoft Outlook, Microsoft Excel, NextGen, Meditech, Meditech Expanse, and the usage of the intranet.
• Ability to operate a copier, fax machine, and printer.
• Excellent verbal and written communication skills to interact effectively with patients, customers, employees, and senior leaders.
• Demonstrate the ability to follow verbal and written instructions.
• Interact courteously and professionally with co-workers and other staff, offering assistance as needed.
• Ability to work in a changing environment, accept and give constructive criticism and feedback.
• Work well with others in a team-oriented environment.
• Strong customer service background, including a pleasant disposition and high tolerance level.

Qualifications

• High school diploma or GED required; some college coursework preferred related to Business/Health Sciences.
• A minimum of two years of healthcare experience in revenue cycle billing and collections.
• A minimum of one year of experience in obtaining authorization and predetermination.
• Understanding of medical terminology, CPT, and ICD-10 codes.
• Extensive knowledge of health insurance plans, including Medicare, Medicaid, HMOs, and PPOs.

Physical Demands

• Sedentary to light work, lifting up to 15 pounds on an infrequent basis (less than one lift every three minutes).
• Work is mostly done sitting, but a certain amount of walking or standing is often necessary.

Ergonomic Risk Factors: Repetition and awkward posture, including repeated or prolonged reaching, twisting, bending, kneeling, squatting, working overhead, or holding fixed positions.

Working Conditions

Bloodborne Pathogens Exposure Risk: Category C – No exposure to blood or body fluids.