Summary

The Authorizations Representative is responsible for obtaining written, electronic and telephone prior authorizations as requested by insurance payers/providers for our patients within established timeframes and guidelines. This position also completes data entry and provider notification to ensure timely service to members and answers a high volume of calls within contract-mandated timeframes.

Essential Duties and Responsibilities

Registration and Verification

• Responsible for obtaining and communicating pre-authorization as needed per insurance company requirements for procedures, DME, imaging, labs, medications etc.
• Responsible for tracking, obtaining, and extending authorizations from various carriers in a timely manner, requesting input from appropriate team members as needed. Appeals for additional services (extended stays, visits, authorization extension, letter of medical necessity) and refers to additional resources when necessary.
• Record insurance information to maintain data through the Referral/Insurance Verification process and communicates insurance information to pertinent staff including therapists, coding, and finance. Independently maintains and works from the electronic medical record and additional databases.
• Responsible for sending the Plan of Care/imaging/referral notes, etc. to insurance companies.
• Track a significant amount of data and information, preparing and producing meaningful reports and information.
• Works closely with clinical staff to ensure CPT codes and ICD-10 codes are accurate.
• Obtains information necessary to complete the pre-authorization and scheduling of an order.
• Researches and works with staff and billing company in resolving and resubmitting denied, rejected, and incorrectly paid claims including a review of timely submission and other processing procedures.
• Responds professionally to all inquiries from patients, staff, and payors in a timely manner, as well as keeps patients informed of authorization status if within 72 hours of the scheduled date.
• Keeps management informed of changes in authorization process, insurance policies, billing requirements, rejection, or denial codes as they pertain to claim processing and coding.
• Accurately documents patient accounts of all actions taken.
• Educates clinic management and staff regarding changes to insurance and regulatory requirements.
• As necessary, negotiates a work improvement plan with management to raise work quality and quantity to standards.
• Ensures reports have minimal errors by developing, correcting, and executing comprehensive testing plan of modifications, new codes, etc.
• Identify opportunities for process improvement for receipt of data and reporting.
• Ability to meet established deadlines timely, accurately and with a sense of urgency.
• Responsible for obtaining complete and accurate insurance information, benefit verification, accurately interpreting benefit plans and investigating pertinent details. Notifies supervisor of known or potential insurance coverage issues
• Review information for admission and continued visit management including type and duration of service, authorization and treatment codes, re-authorization and continued visit requirements necessary for ongoing treatment and payment.
• Review scheduled procedures and orders to ensure they follow guidelines and are scheduled correctly.
• Order medications following authorization approval, such as Botox, Synvisc, etc.
• Perform financial analysis of each case and informs patient of financial responsibility if requested.
• Other duties as assigned/ required.
• The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job related tasks other than those stated in this description.

Core Competencies

Action Orientation - Targets and achieves results, overcomes obstacles, accepts responsibility, establishes standards and responsibilities, creates a results-oriented environment, and follows through on actions.

Communications - Communicates well both verbally and in writing. Effectively conveys and shares information and ideas with others. Listens carefully and understands various viewpoints. Presents ideas clearly and concisely and understands relevant detail in presented information.

Creativity/Innovation - Generates novel ideas and develops or improves existing and new systems that challenge the status quo, takes risks, and encourages innovation.

Critical Judgment - Possesses the ability to define issues and focus on achieving workable solutions. Consistently does the right thing by performing with reliability.

Customer Orientation - Listens to customers, builds customer confidence, increases customer satisfaction, ensures commitments are met, sets appropriate customer expectations, and responds to customer needs.

Interpersonal Skills - Effectively and productively engages with others and establishes trust, credibility, and confidence with others.

Leadership - Motivates, empowers, inspires, collaborates with, and encourages others. Builds consensus when appropriate. Focuses team members on common goals.

Teamwork - Knows when and how to attract, develop, reward, and utilize teams to optimize results. Acts to build trust, inspire enthusiasm, encourage others, and help resolve conflicts and develop consensus in creating high-performance teams.

Professional Requirements

• Meets dress code standards and adheres to policies.
• Completes annual education requirements.
• Maintains regulatory requirements.
• Maintains patient confidentiality at all times.
• Reports to work on time and as scheduled, completes work within designated time.
• Wears identification while on duty, uses computerized punch time system correctly.
• Completes in-services and returns in a timely fashion.
• Attends annual review and department in-services, as scheduled.
• Attends staff meetings annually, reads and returns all monthly staff meeting minutes.
• Represents the organization in a positive and professional manner.
• Actively participates in performance improvement and continuous quality improvement (CQI) activities.
• Complies with all organizational policies regarding ethical business practices.
• Communicates the mission, ethics, and goals of the hospital, as well as the focus statement of the department.
• Promotes professional growth of subordinates by sharing knowledge and/or directing them to sources if information appropriate to given situation. Utilizes journals, books, etc. to learn and/or improve new techniques and equipment.
• Assists other staff members in performing any duty that enhances the delivery of patient care.
• Exceptional organization skills & strong attention to detail.

Regulatory Requirements

• High school diploma.
• Knowledge of medical terminology, procedures, and diagnosis
• Knowledge of computer and relevant software applications
• Minimum two (2) years insurance resolution experience resolving issues with patients preferred.
• Demonstrate knowledge of state, federal, and third-party claims processing required.
• Clinical experience with electronic health record software
• Educated on and compliant with HIPAA regulations; maintains strict confidentiality of client information.

Skills

• Ability to communicate effectively in English, both verbally and in writing.
• Planning and organizing.
• Information collection and management.
• Customer service skills.
• Excellent interpersonal and organization skills.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and hear. This position is very active and requires repetitive motions, standing, walking, bending, kneeling, and stooping all day. The employee must frequently lift or move items weighing up to 20 pounds.