Authorization Specialist- Managed Care Progra

Position:         Authorization Specialist – Managed Care Program 

Reports To:    RCM Manager

Position Summary: The authorization specialist works in collaboration with the multidisciplinary team to gather clinical documentation to justify medical necessity in accordance with Medicaid and Medicare guidelines. The authorization specialist is also responsible for insurance verification and obtaining authorization for inpatient admissions including concurrent authorization requests, retroactive authorization modifications, and discharge notifications as appropriate.

Essential Duties and Responsibilities:

1. Confirms the need for an authorization and takes the appropriate actions to ensure the authorization is obtained.
2. Prioritizes the urgency of the authorization by anticipating the approximate time it may take to obtain the authorization from the insurance company, the complexity of the procedure and the scheduled date of service. 
3. Follows up with insurance company to accelerate responses and expedite urgent/emergent authorizations.
4. Gathering clinical information and applying appropriate medical necessity criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care.
5. Maintain confidentiality of patient care and business.
6. Ensures all needed clinical documentation is completed in order to mitigate billing issues.
7. Completes authorization phone calls every 7 days for patients in the residential program.
8. Documents approved authorization on patient file and provides an update to his/or her direct supervisor. 
9. Assists with other clerical jobs, as needed. 

 Preferred Qualifications: To successfully perform in this position, the employee must be able to execute each duty satisfactorily.  The requirements listed above are representative of the knowledge, skill and/or ability required.  In addition to, having medical billing or insurance authorization experience (strongly preferred), knowledge of medical terminology. Reasonable accommodations will be made to enable employees with disabilities to perform the essential functions.

Education and/or Experience: High School Diploma required. 

Associate degree in Psychology or related field (highly preferred). At least 1 year of experience working in the related field. 

Reasoning Ability:    Ability to apply common sense understanding to carry out instructions furnished in written or oral form.

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. Reasonable accommodations will be made to enable employees with disabilities to perform the essential functions. The employee will have to sit and stand for indefinite periods of time.

The employee may occasionally be required to lift and/or move up to fifteen pounds.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations will be made to enable employees with disabilities to perform the essential functions. Most of the work is in a climate-controlled facility. The noise level varies from quiet to moderate to loud.