Referral and Authorization Specialist - Practice Support

Frederick Health•Frederick, MD

6d•Onsite

About The Position

Supports, and is responsible for incorporating into job performance, the Frederick Health (FH) mission, vision, core values and customer service philosophy and adheres to the FH Compliance Program, including following all regulatory requirements and the FH Standards of Behavior. Under the direction of the Patient Access and HIM Manager and Department Lead, this position is responsible for patient insurance carrier referrals, insurance authorizations for in-house procedures/services, insurance eligibility, benefits, pre-determinations and price estimations. These responsibilities and requirements must be met prior to the delivery of ambulatory services. Responsible for verifying patient demographic and financial information for all insurances and self-pay accounts. Primary function of the Referral Authorization Specialist position is to provide premier customer service to internal and external customers in determining patient coverage, authorizations need, predetermination and patient estimations for care, in compliance with the No Surprise Act.

Requirements

Attention to detail, with the ability to analyze and determine the type of data needed to complete various types of patient registration functions.
Maintain a working knowledge of all insurance requirements for authorizations, referrals and price estimates.
Demonstrate ability to manage time, deadlines, multiple requests and priorities, maintain productivity and exercise good judgment with minimal supervision.
Clinical knowledge, to include medical terminology, medications, procedures/radiology, procedures and surgeries from all different medically specialty services.
Ability to apply policies and procedures regarding data security and patient confidentiality (HIPAA) to prevent inappropriate release of patient information.
Proficiency in the use of computer software such as Microsoft Word, Microsoft Outlook, Microsoft Excel, NextGen, Meditech, Meditech Expanse, and the usage of the intranet.
Ability to operate a copier, fax machine, and printer.
Excellent verbal and written communication skills to interact effectively with patients, customers, employees and Senior Leaders.
Demonstrate the ability to follow verbal and written instructions.
Always interact with co-workers and other staff in a courteous and professional manner, and offering assistance as needed.
Able to work in a changing environment, accept and give constructive criticism and feedback.
Work well with others in a team-oriented environment.
Strong customer service background to include a pleasant disposition and high tolerance level.
High school diploma or GED required.
A minimum of two years healthcare experience in revenue cycle billing and collections.
A minimum of one year experience in obtaining authorization and pretermination.
Understanding of medical terminology, CPT and ICD-10 codes.
Extensive knowledge of health insurance plans including, Medicare, Medicaid, HMO’s and PPO’s required.

Nice To Haves

Some college coursework preferred related to Business/Health Sciences

Responsibilities

Complete the pre-determination and authorization process prior to services being rendered.
Serve as primary resource for obtaining patients’ referrals.
Obtain primary care physician approval for patients’ referrals as required by the insurer.
Maintain a working knowledge of all insurance requirements related to referrals, authorizations, pre-determinations and medical necessity.
Calculate price estimations, per payer fee schedule, prior to services being rendered.
Maintain updated knowledge of providers within the surrounding areas and insurance participation.
Complete referrals for patients to participating providers within the appropriate network to maintain maximum financial incentives/reimbursement from payers as directed by the provider.
Assist the providers and clinical staff in identifying the appropriate network/healthcare provider to use as a referral.
Maintain knowledge of organizational quality metrics and goals.
Maintain knowledge of online insurance eligibility verification systems.
Collaborate with designated clinical contacts regarding encounters that require escalation for peer-to-peer review.
Facilitate submission of clean claims and reduction in payer denials by adhering to both organizational and departmental policies and procedures to maintain departmental productivity and quality goals.
Answer incoming phone inquiries related to referrals, pre-authorizations and medical necessity.
Review statistical data pulled from Cisco finesses to ensure time efficiency on calls and completing self-assessments as well as review assessments on calls reviewed by management.
Offer to enroll patients in the patient portal when non-enrolled.
All other duties as assigned.