Insurance Authorization Specialist

Beth Israel Lahey Health•Plymouth, MN

1d•Onsite

About The Position

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives. This position requires identifying, initiating, securing, and confirming that referral and pre-authorizations are in place and that medical necessity has been met for patients to receive services. This includes timely payer notification of admissions, contacting insurance companies to obtain benefit and policy limitations, verifying insurance eligibility, and updating accounts with accurate information. The role requires maintaining a working knowledge of insurance requirements, navigating payer websites to submit authorization requests and upload clinical documentation, and using hospital software to identify requirements, guidelines, and policies related to notification, authorizations, referrals, and medical necessity. It also involves establishing working relationships with hospital departments and physician offices to resolve issues with scheduled services and assisting with the research of insurance denials.

Requirements

HS Diploma or equivalent.
Knowledge of medical terminology is required.
Problem solving techniques.
Strong interpersonal skills.
Effective oral and written communication skills.
A minimum of 2 years in Patient Access /Patient Registration, Patient Accounts, or Physician Office in which there was direct hands on of verification of eligibility, obtaining referrals and authorizations, and/or registration of demographic and insurance information.
Demonstrated ability to function independently, follow directives and perform job responsibilities with minimal supervision.
Possess good decision making skills and the ability to work under pressure maintaining a courteous demeanor.
Demonstrated computer skills.
The ability to stay focused and work at an efficient pace with accuracy is required.

Nice To Haves

EPIC experience a plus.

Responsibilities

Provide exceptional customer service displaying courtesy and professionalism at all times while interacting with patients, families, physicians or other personnel in person or on the telephone.
Review Outpatient and Inpatient accounts for accurate insurance information using the electronic eligibility software and/or a telephone call to the payer.
Review Outpatient and Inpatient accounts to identify if notification, authorization and/or referrals are required and obtains prior to service being rendered and within payer guidelines.
Review Outpatient and Inpatient accounts and verifies that the diagnosis provided by the physician meets the payer’s medical necessity policy for the upcoming service/procedure.
Review physician documentation against payer medical policy criteria for requested services to ensure that the criteria has been met and documented prior to submitting for authorization and/or approving the appointment.
Monitor accounts in Observation nearing 48 hrs and request from Utilization Review an update on discharge status.
Maintain a working knowledge and understanding of each department’s appointment types, CPT Codes and ICD-10 Diagnosis Codes in order to obtain accurate information from insurance companies, use in submission of authorizations, clear accounts for medical necessity and speak knowledgeably with physician offices and insurance companies.
Timely review and submission of authorization, referral and medical necessity to ensure that patients are able to keep scheduled appointments all while following departmental procedure.
Monitor physician level of care changes and length of stay in order to make new notifications and/or request additional inpatient days.
Facilitates timely telephone calls and on-line inquiries regarding status of outstanding referrals and/or authorizations and notifications.
Review surgical bookings for eligible insurance and identify if a co-payment and/or deductible is required and document the information in Meditech.
Obtain drug authorizations for certain surgical procedures where drug falls outside of the surgical authorization.
Rectify, review and clear individual and batch Worklist, errors and alerts to ensure account quality and accuracy.
Coordinate Peer to Peer reviews between insurance Physician Reviewer and hospital ordering physician when procedure or drug has been denied.
Identify surgical accounts that have been postponed or cancelled and remove authorizations that are no longer valid and request updated authorizations.
Troubleshoot insurance denials and billing discrepancies and prepare paperwork for appeal submission.
Identify daily and make notification to management of “accounts at risk” that may result in rescheduling of appointment due to authorization or medical necessity issue.
Document per department protocol, conversations with Insurance Company Representatives regarding authorization requirements in the event misinformation was provided.
Assist other Insurance Authorization Specialist when volume shifts occur and/or staffing for vacation and/or sick calls.
Performs other duties, special projects as assigned or requested.