Clinical Authorization Specialist

WVU Medicine

About The Position

Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you’ll find other important information about this position. Support the authorization department through utilization of clinical knowledge with associated treatments. Provides analysis of medical records to determine medical necessity in the clinical record and provides feedback to the providers and clinical team. Navigates high dollar treatments and provides additional clinical support as well as potential patient contact.

Requirements

High school graduate or equivalent.
Current Licensed Practical Nurse license issued by the state in which services will be provided or current multi-state Licensed Practical Nurse license through the enhanced Nurse Licensure Compact (eNLC).
Two (2) years of healthcare experience.
Excellent oral and written communication skills.
Excellent customer service and telephone etiquette.
Must demonstrate the ability to use tact and diplomacy in dealing with others.
Knowledge of ICD9/CPT Coding or Medical Terminology.
Knowledge of third party reimbursement.

Nice To Haves

Associate or advanced degree.
Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).

Responsibilities

Reviews the medical record for clinical documentation in relation to ordered treatment. Provides education to providers in relation to insurance policy of any variances.
Provides coordination of high dollar services that would include analyzing the medical record for medical necessity and provides authorizations. Acts as a point of contact for assigned services that will interact with the clinical leaders in the department.
Researches each request including reviewing medical policy to ensure each requests is processed with minimum delay and risk of denial.
Effectively communicates clinical information with payor to obtain authorization for appropriate level of care and procedure, and documents interactions in patient’s electronic medical record (EMR).
Provides prompt follow up with the Payor to ensure current authorization and accurate payment for the patient’s stay/treatment.
Provides prompt feedback regarding payor determination to Supervisor/Clinic, enabling them to evaluate/redirect the current patient plan of care in order to streamline the delivery of service.
Identifies pre-services denials by third party payor and notifies Supervisor/Clinic for immediate intervention.
Proactively communicates any change in payor information and follows up with payor to ensure services are authorized. Documents all changes and all payor information (i.e. DOS, Service (CPT/HCPC codes), LOC, Reference #, Authorization #, contact and phone number, and website used) appropriately.
Based on assigned area, communicates with patient to obtain any and all information needed, scheduling, Charge Capture, verify and obtain referrals and pre-authorizations both for services provided within the hospital system and outside facilities.
Communicates with the patient in regards to insurance information needed, the anticipated self-pay portion including co-payments/deductibles/co-insurance. Provides available denial information and appeal options to the patient.
Completes assigned appeals for retro-authorizations focusing on medical necessity. Utilizes the physician documentation when appropriate to support services rendered
Notifies financial counseling of all patients with a high out of pocket. Refers self-pay patients with limited or exhausted benefits to financial counselors and/or social worker to determine eligibility.
Researches and resolves denials and communicates findings to department and/or Clinical Denial teams.
Maintains confidentiality/HIPPA according to policy when interacting with patients, physicians, families, co-workers and the public regarding demographic/clinical/financial information.
Reviews medical records and applies information to payor policies or LCD/NCD. Notifies treatment team of missing documentation pre-service.
Maintains assigned Work Queues in a timely and effective manner.
Participates in on-going educational activities to develop, maintain and enhance professional expertise as determined by leadership.