Pre-Authorization Specialist - FCH
Pre-Authorization Specialist - FCH
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Job Description
DUTIES:
The PreAuthorization Specialist is a member of the PreAuthorization Department who is responsible for verifying eligibility obtaining insurance benefits and ensuring precertification authorization and referral requirements are met prior to the delivery of inpatient outpatient and ancillary services. This individual determines which patient services have third party payer requirements and is responsible for obtaining the necessary authorizations for care. The PreAuthorization Specialist provides detailed and timely communication to both payers and clinical partners in order to facilitate compliance with payer contractual requirements and is responsible for documenting the appropriate information in the patients record. Other duties as assigned.
JOB REQUIREMENTS:
Minimum of two years experience in hospital billing/preauthorization or insurance verification with demonstrated knowledge of health insurance plans including: Medicare Medicaid HMOs and PPOs required.
Prior experience in a business office position with strong customer service background preferred. Education High School diploma.
Exceptional customer relations skills required.
Knowledge of online insurance eligibility systems. Excellent typing and computer skills.
Familiarity with Medical Terminology. Demonstrated ability to efficiently organize work and maintain a high level of accuracy and productivity.
JOB STANDARDS:
Verifies insurance eligibility and benefit levels to ensure adequate coverage for identified services prior to receipt. Successfully works with payers via electronic/telephonic and/or fax communications.
Responsible for verification and investigation of precertification authorization and referral requirements for services.
Coordinates and supplies information to the review organization (payer) including medical information and/or letter of medical necessity for determination of benefits. Collaborates with designated clinical contacts regarding encounters that require escalation to peertopeer review. Communicates with patients clinical partners financial counselors and others as necessary to facilitate authorization process.
Facilitates submission of clean claims and reduction in payer denials by adhering to both organizational and departmental policies and procedures and maintaining departmental productivity and quality goals. Appropriately prioritizes workload to ensure the most urgent cases are handled in a timely manner. Completes accurate documentation in both the Auth/Cert and Referral Shells.
Completes notification to all payers via electronic/fax/telephonic means within 24 business hours of service to ensure compliance with Managed Care contractual requirements. Determines Medicare primacy based on Federal guidelines. Determines inpatient Medicare coverage for days exhausted and hospice entitlement.
Ensures timely and accurate insurance authorizations are in place prior to services being rendered. Follows departmental policies and procedures when necessary authorization is not obtained prior to service date.
Answers provider staff and patient questions surrounding insurance authorization requirements.
SKILLS:
Minimum of two years experience in hospital billing/preauthorization or insurance verification with demonstrated knowledge of health insurance plans including: Medicare Medicaid HMOs and PPOs required. Prior experience in a business office position with strong customer service background preferred. Exceptional customer relations skills required. Knowledge of online insurance eligibility systems. Excellent typing and computer skills. Familiarity with Medical Terminology. Demonstrated ability to efficiently organize work and maintain a high level of accuracy and productivity.
EDUCATION:
High School Diploma required
Employment Type
Full Time
