Referral and Authorization Specialist - Practice Support

Job Summary:

Supports, and is responsible for incorporating into job performance, the Frederick Health (FH) mission, vision, core values and customer service philosophy and 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 is responsible for patient insurance carrier referrals, insurance authorizations for in-house procedures/services, insurance eligibility, benefits, pre-determinations and price estimations. These responsibilities and requirements must be met prior to the delivery of ambulatory services. Responsible for verifying patient demographic and financial information for all insurances and self-pay accounts. Primary function of the Referral Authorization Specialist position is to provide premier customer service to internal and external customers in determining patient coverage, authorizations need, predetermination and patient estimations for care, in compliance with the No Surprise Act.

Example of Essential Functions:

• Responsible to complete the pre-determination and authorization process prior to services being rendered
• Extensive knowledge of all areas of registration and scheduling including on-site and outpatient services
• Knowledge of medical insurance guidelines and participations agreements
• Serves as primary resource for obtaining patients’ referrals.
• Obtains 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
• Maintaining updated knowledge of providers within the surrounding areas and insurance participation
• Completes referrals for patients to participating providers within the appropriate network to maintain maximum financial incentives/reimbursement from payers as directed by the provider. Assists the providers and clinical staff in identifying the appropriate network/healthcare provider to use as a referral
• Maintains knowledge of organizational quality metrics and goals
• Maintain knowledge of online insurance eligibility verification systems
• Collaborates with designated clinical contacts regarding encounters that require escalation for peer-to-peer review
• Facilitates submission of clean claims and reduction in payer denials by adhering to both organizational and departmental policies and procedures to maintain departmental productivity and quality goals.
• Answers incoming phone inquiries related to referrals, pre-authorizations and medical necessity.
• Review statistical data pulled from Cisco finesses to ensure time efficiency on calls and completing self-assessments as well as review assessments on calls reviewed by management
• Offer to enroll patients in the patient portal when non-enrolled
• All other duties as assigned  

Required Knowledge, Skills and Abilities

• 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.

• Must demonstrate ability to manage time, deadlines, multiple request and priorities, maintain productivity and exercise good judgement with minimal supervision.
• Clinical knowledge, to include medical terminology, medications, procedures/radiology, procedures and surgeries from all different medically specialty services.
• Must have the ability to apply policies and procedures regarding data security and patient confidentiality (HIPAA) to prevent inappropriate release of patient information.
• Proficiency in the use of 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. Must demonstrate the ability to follow verbal and written instructions.
• Always interacts with co-workers and other staff in a courteous and professional manner, and offering assistance as needed
• Must be able to work in a changing environment, accept and give constructive criticism and feedback
• Must work well with others in a team-oriented environment
• Strong customer service background to include a pleasant disposition and high tolerance level

Minimum Education, Training, and Experience Required:

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

Patient Contact

Must demonstrate and maintain current knowledge and skills in providing appropriate care/

                    Performance of job does not require patient contact

Physical Demands:

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

Ergonomic Risk Factors:

Repetition:  Repeating the same motion over and over again places stress on the muscles and tendons.  The severity of risk depends on how often the action is repeated, the speed of the movement, the required force and muscles involved.

Awkward Posture:  Posture is the position your body is in and its effect on the muscle groups that are involved in the physical activity.  Awkward postures include repeated or prolonged reaching, twisting, bending, kneeling, squatting, working overhead with your hands or arms, or holding fixed positions.

Working Conditions:

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

Reporting Relationship:

Reports to Director Revenue Cycle, Manager of Patient Access and HIM and Department Lead