Clinical Authorization Specialist - High Tech Radiology

Trinity Health•Azusa, CA

14d

About The Position

The Clinical Authorization Specialist reviews, submits, monitors, and resolves issues related to medical-necessity prior authorizations for high-tech radiology services, procedures, and durable medical equipment for IHA patients across multiple offices. The specialist reviews patient records to identify documentation supporting ordered services, contacts insurers or other third parties to obtain authorizations, and communicates authorization status or issues to ordering physicians and practice staff. The position also handles urgent authorizations, verifies procedural and diagnostic codes and insurance information, updates patient records, and tracks pending authorizations. The role works as part of the Call Center team and supports other offices. It may include mentoring team members and assisting with staff training, as well as attending required meetings and trainings, participating in committees, and completing special projects. The specialist is expected to maintain confidentiality and comply with organizational policies, safety practices, training requirements, and the Trinity Health Code of Conduct. The position operates in a typical office environment with frequent interruptions and substantial interaction with people, which may involve stress and competing priorities.

Requirements

Undergraduate degree or associate degree in healthcare, or graduation from an accredited LPN, PTA, radiology technician or technologist, respiratory therapy, ultrasound, or medical assistant program.
One of the following credentials: valid, unrestricted Michigan LPN license; valid, unrestricted Michigan Physical Therapy Assistant license; valid, unrestricted Michigan Respiratory Therapist license; radiology technician or technologist certification; ultrasound technician certification; or medical assistant certification through a listed certifying agency (AAMA, AMT, NCCT, NHA, NAHP, or AMCA).
1–3 years of previous clinical experience.
3–5 years of experience with insurance referrals, prior authorizations, or other relevant medical office experience.
Proficiency in medical terminology and knowledge of major health plans and insurance processes.
Knowledge of obtaining medical-necessity authorizations across multiple offices.
Strong knowledge of multiple imaging modalities, disease processes, and appropriate testing.
Knowledge of ICD-10 and CPT coding.
Ability to perform mathematical calculations and data collection and review assignments.
Proficiency with desktop and Windows-based computer systems, electronic medical records, Microsoft 365 (including strong Excel skills), email, e-learning, intranet, and computer navigation; ability to use other required software.
Ability to track pending authorizations across multiple offices and document steps, processes, and procedures.
Excellent written and verbal communication, including communicating with insurers, telephone etiquette, and ability to understand and respond to detailed instructions.
Ability to speak to groups in person or virtually and communicate effectively with medical offices, physicians, clinical and clerical staff, and diverse groups.
Ability to work collaboratively, maintain a courteous and friendly demeanor, cross-train in other practice areas, and manage multiple priorities and time constraints.
Sound judgment and problem-solving skills; knowledge of clinical-care compliance, patient privacy, and medical-office practices.
Ability to handle patient and organizational information confidentially.
Successful completion of the IHA competency-based program within the introductory and training period.
Ability to meet the role’s physical expectations, including frequent keyboarding, phone work, charting, and computer use; occasional walking and lifting up to 5 pounds; sufficient vision and manual dexterity for office equipment; and ability to hear and speak well enough to conduct business in English by phone or face to face for extended periods.

Responsibilities

Review, submit, monitor, and resolve issues concerning prior authorizations for high-tech radiology services, procedures, and durable medical equipment.
Communicate professionally with ordering providers, practice support staff, and insurance company representatives.
Review patient medical records—including history, labs, pathology, imaging reports, emergency department records, and consultations—to identify documentation relevant to ordered services.
Perform data collection and data review assignments.
Contact insurers or appropriate third parties and obtain authorizations.
Update the electronic medical record with authorization approval or denial information and follow up with ordering physicians about status or issues.
Monitor in-baskets, email, and fax servers as applicable, and respond to correspondence promptly and accurately.
Obtain urgent authorizations for same-day or next-day services.
Verify procedural codes, diagnostic codes, and insurance information.
Monitor authorizations and denials and follow up as necessary.
May mentor team members and assist with training new and existing staff.
Support other offices, attend required meetings and trainings, and participate in committees as requested.
Perform other duties and special projects as assigned.
Work effectively as a Call Center team member, maintain confidentiality, follow safety and organizational standards, and use resources efficiently.
Maintain relevant licensure or certification and continuing education credentials when applicable.