Revenue Authorization Specialist II

POSITION DESCRIPTION:

This position is remote, but does need to reside in the state of Michigan.

The Revenue Authorization Specialist II is responsible for all aspects of the authorization/pre-certification, referral process and identifies amendments/retros to help maximize revenue for departments when CPT (Current Procedural Technology) codes for technologies and services change. Assists in maintaining charge review and claim edit registration work queues and identifying trends to optimize workflows/education needed.

ESSENTIAL JOB FUNCTIONS:

1. Contacts insurance companies via appropriate methods and obtains pre-certifications and authorizations.
2. Obtains urgent authorizations same day, next day.
3. Verifies correct procedural and diagnostic codes and insurance verification.
4. Monitors in basket, email, and fax server if applicable. Follows up on correspondence timely and accurately.
5. Monitors authorizations or denials and follows up, as necessary.
6. Generates authorization information for physicians, patients, and health plans.
7. Obtains pre-certifications, insurance and testing authorizations for medical procedures.
8. Communicates denials to appropriate staff and next steps.
9. Acts as a liaison among providers, staff, health plan administrators and hospital representatives.
10. Relays clinical information to health plan case managers for special procedure pre-certification and out-of-plan or out-of-network referrals; monitors authorizations or denials and follows up, as necessary.
11. Communicates referral status to staff and physicians; ensures that authorizations have been processed accurately and in a timely manner to coincide with patient treatment plan.
12. Assists offices in resolving billing discrepancies and any other referral/authorization issues.
13. Participates in revenue targeted projects and addresses opportunities and barriers as they arise.
14. Answers incoming calls.
15. Supports other offices, attends required meetings and training, performs research, e-learning to stay current on best practices and participates in committees as requested.
16. Handles amendments and retro-authorizations to recoup revenue.
17. Handles retro-authorizations in the retro-authorization work queue.
18. Identifies opportunities to prevent denials future state.
19. Assumes ownership of the PB REG Newborn Review work queue.
20. Resolves issues in the Hospital PB REG Charge Review and Claim Edit work queues.
21. Assists with special projects and assumes additional duties as assigned. Scans and files documents.

ORGANIZATIONAL EXPECTATIONS:

1. Creates a positive, professional, service-oriented work environment for staff, patients, and family members by supporting the mission and values of both IHA and Trinity Health.
2. Must be able to work effectively as a member of the Revenue Site Operations team.
3. Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management.
4. Successfully completes IHA’s “The Customer” training and adheres to IHA’s standard of promptly providing a high level of service and respect to internal or external customers.
5. Maintains knowledge of and complies with IHA standards, policies and procedures.
6. Maintains complete knowledge of office services and in the use of all relevant office equipment, computer and manual systems.
7. Maintains strict patient and employee confidentiality in compliance with IHA and HIPAA guidelines.
8. Serves as a role model by demonstrating exceptional ability and willingness to take on new and additional responsibilities. Embraces new ideas and respects cultural differences.
9. Uses resources efficiently.
10. If applicable, responsible for ongoing professional development – maintains appropriate licensure/certification and continuing education credentials, participates in available learning opportunities.

MEASURED BY:

Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position.

ESSENTIAL QUALIFICATIONS:

EDUCATION:  Associate degree in health care or a related field and specialized training or equivalent combination of education and experience.

CREDENTIALS/LICENSURE:  None

MINIMUM EXPERIENCE:  3 to 4 years’ experience with insurance referrals, prior authorization or other relevant professional revenue cycle experience.

POSITION REQUIREMENTS (ABILITIES & SKILLS):

1. Knowledge of medical terminology and procedures at the level needed to perform responsibilities.
2. Proficient knowledge of major health plans and insurance processes.
3. Excellent written (legible), verbal and face-to-face communication skills, including ability to effectively explain relevant insurance information to patients, as well as communicate with insurance plans and internal customers.
4. Excellent communication skills in both written and verbal forms, including proper phone etiquette. Ability to speak before groups of people, either in-person or virtually.
5. Proficient/knowledgeable in patient care procedures and organizational policies related to position responsibilities.
6. Service-oriented; responsive to customer needs and courteous in approach.
7. Proficient in operating a standard desktop and Windows-based computer system, including but not limited to, electronic medical records, NextGen, PowerChart, EPIC, Microsoft Word /Excel/Outlook, intranet and computer navigation.
8. Ability to compute mathematical calculations.
9. Ability to work independently and collaboratively in a team-oriented environment; displays professional and friendly demeanor.
10. Ability to work effectively with various levels of organizational members and diverse populations including IHA staff, patients, family members, vendors, outside customers and couriers.
11. Assumes ownership of assigned tasks, prioritizes work with/without leader input and moves projects to completion (in a timely manner).
12. Good organizational and time management skills to effectively juggle multiple priorities and time constraints.
13. Ability to exercise sound judgement and problem-solving skills.
14. Ability to handle patient and organizational information in a confidential manner.
15. Helps to identify problems, offer solutions and participate in their resolution.
16. Ability to travel to other office/practice sites and meeting and training locations.
17. Successful completion of IHA competency-based program within introductory and training period.

MINIMUM PHYSICAL EXPECTATIONS:

1. Physical activity that often requires keyboarding, filing and phone work.
2. Physical activity that often requires extensive time working on a computer.
3. Physical activity that sometimes requires walking, standing, bending, stooping, reaching, and/or twisting.
4. Physical activity that sometimes requires lifting, pushing and/or pulling under 30 lbs.
5. Specific vision abilities required include close vision, depth perception, peripheral vision, and the ability to adjust and focus.
6. Manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator, and other office equipment.
7. Must hear and speak well enough to conduct business over the telephone or face to face for long periods of time in English.