Authorization Specialist

Under the direction of the Central Scheduling Manager, coordinates and facilitates prior authorizations for scheduled procedures at Duncan Regional Hospital. Maintains communication with physicians/providers and their office staff to promote positive patient outcomes and a successful rapport with those offices. Communicates effectively with the patient, physician/provider offices, insurance companies, and various hospital departments to coordinate care and ensure prior authorizations are in place prior to scheduled procedures. Coordinates with all Central Scheduling (CS) staff to ensure prior authorizations are obtained in an efficient and timely manner.

RESPONSIBILITIES (ESSENTIAL FUNCTIONS):

• Provides prior authorization of all CS procedures to ensure coverage for claim payment. 
• Makes direct contact with physicians/providers, nurses, and patients as well as insurance companies and their clerical or clinical staff. 
• Acts as a liaison between patients, physicians/providers, clinical department, and insurance companies.
• Requests, follows up, and secures prior-authorizations prior to services being performed. 
• Receives requests for prior authorizations and ensures that they are properly and closely monitored within department standards.
• Reviews accuracy and completeness of information requested and ensures that all supporting documents are present and contacts physician/provider offices to obtain additional information, as needed.
• Submits medical records to insurance carriers by either website, phone, or fax to expedite prior authorizations processes. Processes requests within required timelines.
• Completes documentation of referrals in software to include the authorization number, number of visits, and the authorization period to ensure claims are paid in a timely manner. Requests additional information from providers in consistent and efficient manner.
• Coordinates notifications to members, physicians/providers, and CS team members as required to obtain missing information, manage pended requests, and communicates prior authorization determinations.
• Clearly documents all communications and contacts with patients, providers, insurance companies, and CWS team members in MediTech.
• Obtains additional clinical information for denials and submits appeals to the plan for further consideration, when necessary.
• Works daily pending pre-authorization file.
• Ensures referral provides accurate information to include patient and provider identification information, clinic, or procedure requested and appropriate billing codes.
• Contacts plans to extend authorization dates, obtain additional visits, and for urgent/priority prior authorizations, as needed.
• Requests and follows through with retroactive prior authorization for urgent procedures, when needed.
• Follows through on delivery of requested items to insurance company.
• Documents all prior authorization information including approval dates, billing units, procedure codes, and prior authorization number in patient account within Meditech.
• Scans documentation into the EMR system, as necessary.
• Manages correspondence with insurance companies and internal customers, as required. 
• Performs follow up contact with the insurance company or physician/provider office based on pending documentation or approval.
• Reviews insurance denials, notifies scheduler and physicians/provider offices, and documents accounts in Meditech.  
• Obtains insurance pre-certification from the referring physician/provider office and contacts insurance carriers for confirmation.
• Communicates any insurance/prior authorization changes or trends among CS team members.
• Identifies potential quality of care issues, service, or treatment delays and intervenes where clinically appropriate.
• Collaborates with and teaches other team members best practices for managing and submitting prior authorizations.
• Handles patient confidential information and adheres to all HIPAA expectations.
• Collaborates with other departments to assist in obtaining prior authorizations/appeals
• Regular attendance and punctuality for scheduled shifts.
• Maintains professional and technical knowledge through continuing education opportunities including internal and external educational offerings.
• Must adhere to safety protocols at all times.
• Per DRH policy, all required conditions of employment must be met and maintained including required vaccinations.
• Implement DRH Standards of Behavior and exhibit behaviors consistent with DRH core values.
• Performs other related duties as assigned.

Minimum Qualifications: Communication skills including fluency in oral and written English. Basic computer skills including the ability to send/receive email, navigate information technology associated with the position, and use Electronic Health Record information tools. Ability to remain flexible to quickly adapt to urgent situations. Ability to adapt procedures, processes, tools, equipment, and techniques to accomplish the requirements of the position.

Education and/or Experience:  High school diploma or equivalent required. Excellent customer service and verbal/listening/written communication skills required. Must be organized and have the ability to multi-task. Proven organization and time management skills are crucial. Maintains a level of productivity suitable for the department. Demonstrate and apply knowledge of medical terminology and high proficiency of general medical office procedures including HIPPA regulations. Excellent telephone etiquette and customer service skills. Prior scheduling experience preferred. Previous medical and insurance experience preferred. Knowledge of anatomy, physiology, or medical terminology preferred.

Certifications, Licenses, Registrations:  For those positions requiring travel, a current valid driver’s license and automobile liability insurance must be maintained.

Non Safety-Sensitive Position

As a condition of employment, vaccinations are required per DRH Policy. Medical and Religious Exemptions are available upon request.