Authorization Specialist (Full-time/Cody)

Responsible for performing the authorization functions with insurance carriers. Coordinate with/educate physicians, nursing staff and other health care providers on the authorization process and requirements. Works as a patient advocate and functions as a liaison between the patient, staff and payer to answer reimbursement questions and avoid insurance delays. Tracks, documents, and monitors authorizations. Implements check and balance systems to ensure timely compliance.

Essential Job Functions

• Supports and models behaviors consistent with Billings Clinic’s mission, vision, values, code of business conduct and service expectations. Meets all mandatory organizational and departmental requirements. Maintains competency in all organizational, departmental and outside agency standards as it relates to the environment, employee, patient safety or job performance.
• Coordinates authorization process ensuring authorization has been obtained.
Identifies and initiates precertification/authorization requirements for individual payers and communicates with payer sources in a timely manner to obtain necessary pre-certification/authorization.
• Documents and maintains patient specific precertification/authorization data within the required information systems. Documents and tracks authorizations using established process.
• Reports denials and/or delays in the precertification/authorization process to physicians/other health care providers and/or the patient.
• Develops and maintains collaborative working relationships with payers and health care team.
• Reports non-compliance issues to department specific leadership team.
• Works with Medical Staff Office validating provider enrollment and NPI numbers.
• Tracks and verifies that precertification/authorization has been received either verbally or written.
• Communicates status to health care team and patient as needed. Reviews schedules and work lists multiple times throughout the day.
• Makes referrals as needed to ensure patient’s needs are met and precertification/authorization is obtained.
• Reports denials and/or delays in the authorization process to the health care team and/or the patient. Provides information to the patient on the appropriate appeal process for denials as needed.
• Responsible for authorization of pre-scheduled elective inpatient and/or outpatient procedures, diagnostic testing and/or planned medical admissions.
• Reviews CPT-4 codes against Medicare and other payer specific inpatient only lists, if applicable, to assigned departments. Maintains updated list. Ensures correct patient status when pre-certifying. Validates CPT and diagnosis codes match documented physician treatment plan.
• Reviews CPT-4 codes against Medicaid listings of required precertification and/or authorizations. Ensures Passport pre-certification process is met.
• Participates in interdepartmental meetings to coordinate efforts, work through processes, and foster communication.
• Responsible for precertification for Billings Clinic campus and regional outreach services
• Reviews daily hospital work list to determine if patient’s payer requires authorization/ notification.
• Understands insurance/payer policy language, benefits and authorization requirements upon admission, for concurrent review, and for discharge.
• Conducts concurrent authorization with third party payers during the patient’s stay.
• Conducts follow-up calls, as necessary, to third party payers to complete authorization process validating that all days are authorized.
• Performs all other duties as assigned or as needed to meet the needs of the department/organization.

Minimum Qualifications

Education

• High school graduate or GED equivalent

Experience

• One (1) year of medical insurance claims experience through patient accounts billing or claims adjudication