Summary
TheAuthorizations Representative is responsible for obtaining written, electronicand telephone prior authorizations as requested by insurance payers/providersfor our patients within established timeframes and guidelines. This positionalso completes data entry and provider notification to ensure timely service tomembers and answers a high volume of calls within contract-mandated timeframes.
Essential Duties and Responsibilities
Registration andVerification

• Responsible for obtaining and communicatingpre-authorization as needed per insurance company requirements for procedures,DME, imaging, labs, medications etc.
• Responsible for tracking, obtaining, andextending authorizations from various carriers in a timely manner, requestinginput from appropriate team members as needed. Appeals for additional services(extended stays, visits, authorization extension, letter of medical necessity)and refers to additional resources when necessary.
• Record insurance information to maintain datathrough the Referral/Insurance Verification process and communicates insuranceinformation to pertinent staff including therapists, coding, and finance.Independently maintains and works from the electronic medical record andadditional databases.
• Responsible for sending the Plan ofCare/imaging/referral notes, etc. to insurance companies.
• Track a significant amount of data andinformation, preparing and producing meaningful reports and information.
• Works closely with clinical staff to ensureCPT codes and ICD-10 codes are accurate.
• Obtains information necessary to complete thepre-authorization and scheduling of an order.
• Researches and works with staff and billingcompany in resolving and resubmitting denied, rejected, and incorrectly paidclaims including a review of timely submission and other processing procedures.
• Responds professionally to all inquiries frompatients, staff, and payors in a timely manner, as well as keeps patientsinformed of authorization status if within 72 hours of the scheduled date.
• Keeps management informed of changes inauthorization process, insurance policies, billing requirements, rejection, ordenial codes as they pertain to claim processing and coding.
• Accurately documents patient accounts of allactions taken.
• Educates clinic management and staff regardingchanges to insurance and regulatory requirements.
• As necessary, negotiates a work improvementplan with management to raise work quality and quantity to standards.
• Ensures reports have minimal errors bydeveloping, correcting, and executing comprehensive testing plan ofmodifications, new codes, etc.
• Identify opportunities for process improvementfor receipt of data and reporting.
• Ability to meet established deadlines timely,accurately and with a sense of urgency.
• Responsiblefor obtaining complete and accurate insurance information, benefitverification, accurately interpreting benefit plans and investigating pertinentdetails. Notifies supervisor of known or potential insurance coverage issues
• Reviewinformation for admission and continued visit management including type andduration of service, authorization and treatment codes, re-authorization andcontinued visit requirements necessary for ongoing treatment and payment.
• Reviewscheduled procedures and orders to ensure they follow guidelines and arescheduled correctly.
• Ordermedications following authorization approval, such as Botox, Synvisc, etc.
• Performfinancial analysis of each case and informs patient of financial responsibilityif requested.
• Otherduties as assigned/ required.
• The above statements are only meant to be a representative summaryof the major duties and responsibilities performed by incumbents of this job.The incumbents may be requested to perform job related tasks other than thosestated in this description.

Core Competencies
ActionOrientation - Targets and achieves results, overcomes obstacles, acceptsresponsibility, establishes standards and responsibilities, creates aresults-oriented environment, and follows through on actions.
Communications - Communicates well both verbally and in writing. Effectively conveys andshares information and ideas with others. Listens carefully and understandsvarious viewpoints. Presents ideas clearly and concisely and understandsrelevant detail in presented information.
Creativity/Innovation - Generates novel ideas and develops or improves existing and new systems thatchallenge the status quo, takes risks, and encourages innovation.
CriticalJudgment - Possesses the ability to define issues and focus on achievingworkable solutions. Consistently does the right thing by performing withreliability.
CustomerOrientation - Listens to customers, builds customer confidence, increasescustomer satisfaction, ensures commitments are met, sets appropriate customerexpectations, and responds to customer needs.
InterpersonalSkills - Effectively and productively engages with others and establishestrust, credibility, and confidence with others.
Leadership - Motivates, empowers, inspires, collaborates with, and encourages others.Builds consensus when appropriate. Focuses team members on common goals.
Teamwork - Knows when and how to attract, develop, reward, and utilize teams to optimizeresults. Acts to build trust, inspire enthusiasm, encourage others, and helpresolve conflicts and develop consensus in creating high-performance teams.
Professional Requirements

• Meets dress code standards and adheres topolicies.
• Completes annual education requirements.
• Maintains regulatory requirements.
• Maintains patient confidentiality at all times.
• Reports to work on time and as scheduled,completes work within designated time.
• Wears identification while on duty, usescomputerized punch time system correctly.
• Completes in-services and returns in a timelyfashion.
• Attends annual review and departmentin-services, as scheduled.
• Attends staff meetings annually, reads andreturns all monthly staff meeting minutes.
• Represents the organization in a positive andprofessional manner.
• Actively participates in performance improvementand continuous quality improvement (CQI) activities.
• Complies with all organizational policiesregarding ethical business practices.
• Communicates the mission, ethics, and goals ofthe hospital, as well as the focus statement of the department.
• Promotes professional growth of subordinatesby sharing knowledge and/or directing them to sources if informationappropriate to given situation. Utilizes journals, books, etc. to learn and/orimprove new techniques and equipment.
• Assists other staff members in performing anyduty that enhances the delivery of patient care.
• Exceptionalorganization skills & strong attention to detail.

Regulatory Requirements

• High school diploma.
• Knowledge ofmedical terminology, procedures, and diagnosis
• Knowledge ofcomputer and relevant software applications
• Minimum two (2) years insurance resolution experienceresolving issues with patients preferred.
• Demonstrate knowledge of state, federal, and third-partyclaims processing required.
• Clinicalexperience with electronic health record software
• Educated on andcompliant with HIPAA regulations; maintains strict confidentiality of client information.

Skills

• Ability tocommunicate effectively in English, both verbally and in writing.
• Planning andorganizing.
• Informationcollection and management.
• Customer serviceskills.
• Excellentinterpersonal and organization skills.

Physical Demands
The physicaldemands described here are representative of those that must be met by anemployee to successfully perform the essential functions of this job. Whileperforming the duties of this job, the employee is regularly required to talkand hear. This position is very active and requires repetitive motions, standing,walking, bending, kneeling, and stooping all day. The employee must frequentlylift or move items weighing up to 20 pounds.

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