Referral and Authorization Specialist

Frederick Health • Frederick, MD

34d • $18 - $23 • Onsite

About The Position

The Referral and Authorization Specialist supports Frederick Health’s mission, vision, core values, customer service philosophy, Compliance Program, regulatory requirements, and Standards of Behavior. Under the direction of the Patient Access and HIM Manager and Department Lead, the role handles patient insurance referrals and authorizations for in-house procedures and services, insurance eligibility and benefits, pre-determinations, and price estimates before ambulatory services are delivered. The specialist verifies demographic and financial information for insured and self-pay accounts and provides customer service by helping internal and external customers understand coverage, authorization needs, pre-determinations, and estimated costs in compliance with the No Surprises Act.

This is an on-site, full-time position scheduled Monday through Friday, 80 hours bi-weekly, from 8:30 a.m. to 5:00 p.m. The position does not require patient contact. Work is primarily sedentary, with occasional walking or standing and infrequent lifting of up to 15 pounds. The role has repetitive-motion and awkward-posture ergonomic risk factors and is classified as having no bloodborne pathogen exposure.

The hourly pay range is $17.51–$22.66, based on experience, skills, and education.

Requirements

• High school diploma or GED.
• At least two years of healthcare experience in revenue cycle billing and collections.
• At least one year of experience obtaining authorizations and pre-determinations.
• Understanding of medical terminology, CPT codes, and ICD-10 codes.
• Extensive knowledge of health insurance plans, including Medicare, Medicaid, HMOs, and PPOs.
• Attention to detail and ability to analyze and identify data needed for patient registration functions.
• Working knowledge of insurance requirements for authorizations, referrals, and price estimates.
• Ability to manage time, deadlines, multiple requests, and priorities; maintain productivity; and exercise good judgment with minimal supervision.
• Clinical knowledge of medical terminology, medications, procedures and radiology, and procedures and surgeries across medical specialties.
• Ability to apply policies and procedures for data security and patient confidentiality under HIPAA.
• Proficiency with Microsoft Word, Outlook, and Excel; NextGen; Meditech and Meditech Expanse; and the intranet, as well as ability to operate a copier, fax machine, and printer.
• Excellent verbal and written communication skills, ability to interact effectively with patients, customers, employees, and senior leaders, and ability to follow verbal and written instructions.
• Ability to interact courteously and professionally with coworkers and other staff and offer assistance as needed.
• Ability to work in a changing environment and give and accept constructive feedback.
• Ability to work well in a team-oriented environment.
• Strong customer service background, pleasant disposition, and high tolerance level.

Nice To Haves

• Some college coursework, preferably related to Business or Health Sciences.

Responsibilities

• Complete the pre-determination and authorization process before services are rendered.
• Apply knowledge of registration and scheduling for on-site and outpatient services, medical insurance guidelines, and participation agreements.
• Serve as the primary resource for obtaining patient referrals and obtain primary care physician approval when required by the insurer.
• Maintain working knowledge of insurance requirements related to referrals, authorizations, pre-determinations, and medical necessity.
• Calculate price estimates using payer fee schedules before services are rendered.
• Maintain updated knowledge of providers in surrounding areas and their insurance participation.
• Complete referrals to participating providers in the appropriate network to support payer incentives and reimbursement, and help providers and clinical staff identify appropriate referral networks and providers.
• Maintain knowledge of organizational quality metrics and goals, and online insurance eligibility verification systems.
• Collaborate with designated clinical contacts on encounters requiring escalation for peer-to-peer review.
• Support clean claim submission and reduced payer denials by following organizational and departmental policies and procedures and meeting productivity and quality goals.
• Answer incoming phone inquiries about referrals, pre-authorizations, and medical necessity.
• Review Cisco Finesse statistical data for call time efficiency, complete self-assessments, and review management assessments of calls.
• Offer patient portal enrollment to patients who are not enrolled.
• Perform other duties as assigned.

Benefits

• Health, dental, and vision insurance, available on the first of the month after 30 days of employment for employees working at least 20 hours per week.
• Employer-paid life insurance, short-term income replacement, and long-term disability for eligible employees.
• Paid time off program for eligible employees.
• 403(b) retirement plan with employer match for eligible employees.
• Free financial planning sessions for all employees.
• Educational assistance program.
• Employer-paid Employee Assistance Program.

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED