Authorization Representative

Jefferson Health Plans • Abington, MA

23h • Onsite

About The Position

Coordinates insurance benefits verification and secures prior authorizations for surgical procedures, diagnostic testing, medications, referrals, and related services. Interprets payer-specific authorization requirements and ensures compliance with health plan protocols. Supports revenue cycle operations by performing functions that promote accurate claims submission and timely reimbursement from insurance carriers and patients. Coordinates insurance benefits verification and secures prior authorizations for surgical procedures, diagnostic testing, medications, referrals, and related services. Interprets payer-specific authorization requirements and ensures compliance with health plan protocols. Supports revenue cycle operations by performing functions that promote accurate claims submission and timely reimbursement from insurance carriers and patients.

Requirements

• High School Diploma/GED
• 1 year experience in healthcare insurance verification, prior authorization requirements, and insurance benefits structures.
• Experience working with multiple insurance payers and understanding medical necessity requirements.
• Priorexperience working with electronic health record (EHR) systems and insurance portals.
• Familiarity with clinical documentation and interpretation of treatment plans.
• Knowledge of CPT, ICD-10 and HCPS coding as it relates to authorizations
• Knowledge of patients right and laws relative to patients rights such as HIPPA

Nice To Haves

• Associate’s Degree in health administration, healthcare management or related field preferred.

Responsibilities

• Collaborates with physicians and provider office staff in secure the appropriate authorization, referral based on medical necessity and the patients’ treatment plan.
• Performs medical necessity review to ensure procedures and diagnoses meet payer requirements.
• Obtain authorizations in compliance with network policies and communicates any exception to ordering office, patient, and manager).
• Interfaces with insurance companies, both directly and indirectly, to verify coverage, benefits and obtain precertification.
• Reviews and verifies additional clinical information, insurance authorizations and referrals as needed.
• Monitors work queues and patient schedules to ensure accurate authorization are in place prior to each visit.
• Maintains compliance with benchmark metrics for accounts registered versus scheduled procedures.
• Calculates estimated patient financial responsibility using insurance verification, payer contracts, and self-pay guidelines. and/or self-pay guidelines.

Benefits

• Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts.
• Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.
• All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED