Referral and Authorization Specialist

Frederick Health•Frederick, MD

3d•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 specialist manages insurance referrals, authorizations for in-house procedures and services, eligibility and benefits verification, pre-determinations, and price estimates before ambulatory services are delivered. The role also verifies demographic and financial information for insured and self-pay accounts and helps determine coverage and authorization needs in compliance with the No Surprises Act. The specialist provides customer service to internal and external customers, supports providers and clinical staff in identifying appropriate in-network providers, and helps facilitate clean claims and reduce payer denials. The position is onsite, full-time, Monday through Friday, 80 hours biweekly, from 8:30 a.m. to 5:00 p.m. It is sedentary to light work, with occasional lifting up to 15 pounds and some walking or standing. The role has no exposure to blood or body fluids and does not require patient contact.

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 information needed for patient registration functions.
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 data security and patient confidentiality policies and procedures, including HIPAA.
Proficiency with Microsoft Word, Outlook, and Excel; NextGen; Meditech and Meditech Expanse; and intranet use.
Ability to operate a copier, fax machine, and printer.
Excellent verbal and written communication skills and ability to follow verbal and written instructions.
Professional, courteous interactions with coworkers and staff, and willingness to offer assistance.
Ability to work in a changing environment, accept and give constructive feedback, and work effectively in a team-oriented environment.
Strong customer service background, pleasant disposition, and high tolerance level.

Nice To Haves

Some college coursework related to Business or Health Sciences.

Responsibilities

Complete pre-determinations and authorization processes before services are rendered.
Verify patient insurance eligibility, benefits, demographic information, and financial information for insurance and self-pay accounts.
Obtain patient referrals and primary care physician approvals when required by insurers.
Maintain working knowledge of insurer requirements for referrals, authorizations, pre-determinations, and medical necessity.
Calculate price estimates using payer fee schedules before services are rendered.
Complete referrals to participating providers within the appropriate network to support payer incentives and reimbursement.
Assist providers and clinical staff in identifying appropriate networks and healthcare providers for referrals.
Collaborate with designated clinical contacts on encounters requiring escalation for peer-to-peer review.
Facilitate clean claim submission and reduce payer denials by following organizational and departmental policies and procedures.
Answer phone inquiries about referrals, pre-authorizations, and medical necessity.
Review Cisco Finesse call statistics, complete self-assessments, and review management assessments of calls.
Offer patients who are not enrolled the opportunity to use the patient portal.
Perform other duties as assigned.