Authorization Specialist

OneOncology

About The Position

The Authorization Specialist is responsible for the administrative aspects of outpatient diagnostic testing and procedure benefit verification and authorization. The role verifies insurance requirements for reimbursement before testing or procedures and obtains pre-authorizations for physician orders when required by the patient’s insurance carrier. The specialist supports the financial feasibility of patient care by working with patients, physicians, nurses, social workers, and clinic staff. The role also handles authorization denials and appeals, maintains accurate authorization documentation in the Electronic Medical Record, and stays current on payer requirements and reimbursement methodologies. The specialist may work on departmental projects and assist the Patient Finance Manager with training, projects, and implementations.

Requirements

High school diploma or equivalent.
At least 1 year of prior authorization experience.
Medical insurance background.
Ability to work effectively with all levels of management and colleagues.
Ability to demonstrate initiative, mature judgment, professionalism, and adaptability.
Proficiency with end-user computer applications, including MS Word, Excel, and Outlook, databases, patient scheduling systems, and other medical information systems.
Strong customer service delivery skills.
Ability to use websites, portals, and electronic options to improve efficiency.
Ability to follow oral and written instructions.
Problem-solving skills, creative thinking, and ability to analyze and respond to data.
Effective verbal and written communication skills, including active listening and presenting findings and recommendations.
Multitasking and organizational skills, with strong attention to detail.
Working knowledge of hospice and other payer requirements.
Knowledge of clinic office procedures, medical practice, and medical terminology.
Attendance is an essential job function.

Nice To Haves

Urology authorization experience is highly preferred.

Responsibilities

Obtain pre-authorizations for physician orders for diagnostic testing or procedures as required by the patient’s insurance carrier.
Communicate reimbursement issues and pre-certification requirements to physicians and clinical staff.
Maintain up-to-date documentation of authorization approvals and denials in patient accounts in the Electronic Medical Record.
Communicate with Insurance Authorization Coordinators about the need for updated referrals and terminated insurance coverage.
Notify front office managers and staff when denials require rescheduling or peer-to-peer review by the ordering physician.
Communicate with hospitals and other diagnostic facilities to correct discrepancies.
Provide timely updates to front office and imaging center staff about pending authorization status.
Notify the Clinical Trial team of denied scans for patients on study so that study coverage can be verified.
Stay current on insurance carrier requirements for diagnostic testing and procedures.
Follow management policies and procedures to standardize processes across clinics.
Complete retroactive authorization requests and medically necessary appeals from the denial worklist.
Review payer guidelines for medical necessity, including frequency and prior testing requirements.
Work on departmental projects in specific areas of concern and assist the Patient Finance Manager with staff training, projects, and implementations.
Maintain knowledge of authorization processes, reimbursement methodologies, collection techniques, and collection laws.
Carry out additional responsibilities that support the organization’s mission.