Authorization Specialist - Bend, Oregon

Summit Health•Bend, OR

About The Position

The Authorization Specialist obtains authorizations for surgical procedures, diagnostic testing, medications, durable medical equipment (DME), outgoing referrals, and other services as part of the Revenue Cycle Department. The role requires understanding medical insurance and health-plan clinical policies that determine authorization protocols. The specialist identifies services requiring authorization, verifies insurance eligibility and benefits, completes referrals and prior authorizations, and ensures patient-account information and supporting documentation are accurate. The role also involves investigating denials and appeals, resolving authorization or eligibility issues, communicating with patients, providers, staff, managers, and payers, and working with Reimbursement Department teams to limit denials and support proper reimbursement. Specialists use Epic and other electronic tools to manage schedules, work queues, reports, correspondence, referrals, authorizations, and daily work.

Requirements

High school diploma or GED required.
Experience using standard office technology in a Windows-based environment and the Microsoft Office Suite required.

Nice To Haves

Vocational or technical school diploma preferred.
Two to four years of related experience preferred.
Experience with standard office equipment such as phones, fax machines, copy machines, scanners, and email/voicemail preferred.

Responsibilities

Identify appointments and procedures requiring authorization by monitoring department schedules, system reports, and dashboards.
Determine referral and authorization requirements for patients’ insurance plans using online resources and department workflows.
Apply insurance carrier guidelines, clinical policies, and state guidelines related to referrals and prior authorizations.
Verify insurance eligibility and benefits and update patient insurance information as needed.
Complete referrals and prior authorizations promptly according to department guidelines and workflows.
Communicate with patients, physicians, office staff, and managers to resolve issues that could delay or result in denial of an authorization request.
Use system functions to run reports, document and manage referrals and authorizations, move correspondence, and resolve eligibility and authorization holds within authorized access.
Request, prepare, and identify documentation needed to support medical necessity for services.
Provide supervisors and managers with timely feedback about workflow, reimbursement, and customer-service issues.
Ensure accurate information is entered in patient accounts.
Collaborate with Reimbursement Department teams to limit denials and support proper reimbursement.
Work with team members to meet department deadlines and benchmarks.
Use available electronic tools and systems to organize and process daily work, and anticipate and perform necessary duties.
Maintain patient confidentiality.
Make inbound and outbound phone calls daily.
Select the correct insurance package in Epic and update authorizations and claims to reflect a new insurance package.
Sort work queues and reports to identify and process daily work, including schedules, inbound referral reports, and outgoing referrals.
Move correspondence from the dashboard to the patient’s account.
Communicate and document effectively with physicians, practice-location staff, peers, supervisors, managers, and payers, including case and authorization notations.
Investigate authorization denials and appeals involving insurance or patients.