Clinical Authorization Specialist HFMG - Oncology

Health First•Melbourne, FL

27d

About The Position

The Clinical Authorization Specialist provides a comprehensive, accurate, and timely review of insurance benefits, submissions for authorizations, and creations of cost estimates.

Requirements

Technical Diploma in Practical Nursing.
Two (2) years' in healthcare.
Licensed Practical Nurse (LPN) licensure in the State of Florida.
Proficient in Microsoft Office - Outlook, Word, Excel, PowerPoint.
Working knowledge of managed care and insurance programs.
Ability to work autonomously with minimal supervision.
Ability to prioritize and organize to maximize quality, value, and service.
Ability to adapt to a potentially rapidly changing environment or work process.
Excellent teamwork and collaboration skills.
Working knowledge of managed care and insurance programs.
Meets and maintains productivity and quality metrics set by management.

Nice To Haves

Previous Medical Coding experience in ICD-9, ICD-10, CPT, and HCPCS.

Responsibilities

Gathers prior authorization, precertification, pre-determination on applicable services (such as any office visits, injectables, etc.) that requires a level of authorization from the insurance carrier.
Contacts insurance company(s) as necessary to revise the authorization to ensure payment for services, and to request policy and coverage limits, deductible amounts, co-pays, co-insurance amounts and authorization required.
Submits requested clinical documentation to the insurance company to support the medical necessity of services.
Enters all authorization information into the appropriate system to facilitate correct billing.
Identifies any insurance trends regarding insurance updates and notifies applicable parties.
Processes referrals and submit medical records to insurance carriers to expedite prior authorization processes in accordance with Health First policy and procedures.
Reviews the coding then verifying it is correct and within the guidelines dictated by Centers for Medicare and Medicaid Services (CMS) coding compliance standards.
Obtains insurance authorizations to ensure medical procedures being performed are consistent with the authorization.
Acquires and verify insurance information on all patient files containing insurance.
Provides information and instructions telephonically to patients, meeting the departmental and organizational standards.