Referral Authorization Specialist - Full Time with Benefits

Frederick Health

About The Position

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. The role is responsible for verifying patient demographic and financial information for all insurances and self-pay accounts. The 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.
Must demonstrate ability to manage time, deadlines, multiple request and priorities, maintain productivity and exercise good judgement with minimal supervision.
Clinical knowledge, to include medical terminology, medications, procedures/radiology, procedures and surgeries from all different medically specialty services.
Must have the 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. Must demonstrate the ability to follow verbal and written instructions.
Always interacts with co-workers and other staff in a courteous and professional manner, and offering assistance as needed
Must be able to work in a changing environment, accept and give constructive criticism and feedback
Must 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

Responsible to complete the pre-determination and authorization process prior to services being rendered
Extensive knowledge of all areas of registration and scheduling including on-site and outpatient services
Knowledge of medical insurance guidelines and participations agreements
Serves as primary resource for obtaining patients’ referrals.
Obtains 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
Maintaining updated knowledge of providers within the surrounding areas and insurance participation
Completes referrals for patients to participating providers within the appropriate network to maintain maximum financial incentives/reimbursement from payers as directed by the provider. Assists the providers and clinical staff in identifying the appropriate network/healthcare provider to use as a referral
Maintains knowledge of organizational quality metrics and goals
Maintain knowledge of online insurance eligibility verification systems
Collaborates with designated clinical contacts regarding encounters that require escalation for peer-to-peer review
Facilitates 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.
Answers 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