Insurance Reviewer-Clinical
About The Position
Responsible for working in assigned referral WQs to obtain required referrals/authorizations for requested patient care. Review orders and interpret what services/CPT/HCPCs are required. Perform required follow up until receipt of final decision; if not favorable reach out to provider to request next steps. Provide communication between Authorization Department and sites via email, phone and/or in-basket. Proficient in navigation and interpretation of payer requirements, contracted facilities and payer preferred drugs if applicable. Ability to easily understand and interpret orders and therapy plans to insure accuracy and efficiency of authorization submissions. Based on payer requirements enter request attaching required medical records.
Requirements
- High school degree or equivalent.
- 1 Year Healthcare Insurance in Medical/Hospital environment required.
- 1 Year EMR required.
- 1 Year RCAurh required.
Nice To Haves
- Associates degree in Business Admin/related field preferred.
- Certificate Medical Billing or Insurance preferred.
Responsibilities
- Perform timely review of assigned WQs to ascertain next steps; prioritizing requests based on due date, stat, urgent, etc.
- Monitor and process external order WQs
- Review patient chart for MD orders to determine services/CPTs/HCPCs and reasons for requests.
- Review insurance guidelines. If services requested meet medical necessity, gather data to be prepared for phone call, on-line and/or fax to insurance. If no auth required request a Pre D and return authorization approved.
- If services do not meet payer guidelines, reach out to RCAUTHSUP and/or ordering provider for next steps. If request is denied by insurance, request for peer to peer and/or submit written appeal.
- Enter authorized services into system and all notes pertaining to phone calls
- Provide communication for sites/providers via email, phone and/or in-basket.
- Maintain in box and fax folder; import medical guidelines via E-scan into EPIC.
- Assist in managing in-basket messages; ensuring all have been appropriately responded to within 48 hrs.
- Assist in managing WQ ; ensuring WQ is meeting goal, all WQ notes are updated and any delayed referrals reviewed and identifying trends
- Maintain a 95% or greater audit and productivity score.
- Be able to navigate and trouble shoot authorizations related issues/denials : IE non-contracted facility chosen, non-preferred drug etc.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
