Referral and Authorization Specialist - Practice Support

Frederick Health•Frederick, MD

5d•Onsite

About The Position

Supports the Frederick Health (FH) mission, vision, and core values, adhering to the FH Compliance Program and Standards of Behavior. Under the direction of the Patient Access and HIM Manager and Department Lead, this position is responsible for managing patient insurance carrier referrals, obtaining insurance authorizations for in-house procedures/services, verifying insurance eligibility, benefits, pre-determinations, and calculating price estimations. These responsibilities must be fulfilled before ambulatory services are delivered. The role involves verifying patient demographic and financial information for all insurances and self-pay accounts. The primary function is to provide excellent customer service in determining patient coverage, authorization needs, predetermination, and care cost estimations, 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 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, including medical terminology, medications, procedures/radiology, and surgeries from various medical specialty services.
Ability to apply policies and procedures regarding data security and patient confidentiality (HIPAA) to prevent inappropriate release of patient information.
Proficiency in computer software such as Microsoft Word, Microsoft Outlook, Microsoft Excel, NextGen, Meditech, Meditech Expanse, and intranet usage.
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.
Interact with co-workers and other staff in a courteous and professional manner, offering assistance as needed.
Ability 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, including a pleasant disposition and high tolerance level.
High school diploma or GED required.
A minimum of two years of healthcare experience in revenue cycle billing and collections.
A minimum of one year of experience in obtaining authorization and predetermination.
Understanding of medical terminology, CPT, and ICD-10 codes.
Extensive knowledge of health insurance plans, including Medicare, Medicaid, HMOs, and PPOs 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 the primary resource for obtaining patients’ referrals and obtain primary care physician approval for 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.
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 providers and clinical staff in identifying the appropriate network/healthcare provider to use as a referral.
Maintain knowledge of organizational quality metrics and goals.
Collaborate with designated clinical contacts regarding encounters that require escalation for peer-to-peer review.
Facilitate the submission of clean claims and reduction in payer denials by adhering to 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 to ensure time efficiency on calls and complete self-assessments.
Offer to enroll patients in the patient portal when non-enrolled.
Perform other duties as assigned.