The Authorization Rep ensures patients have been cleared for Hospital services, specialty service and office visits. Resolves pre-certification, registration and case-related concerns and determination of patient finanical obligation prior to a patient’s service or visit. Works with insurance carriers, financial counselors, specialists and other ancillary staff. Also responsible for accurately validating patient information and ensuring the patient’s experience is best in class. Relies on guidelines to accomplish tasks. Relies on experience and judgment to complete job. Works under general supervision.
Customer Service
Gathers information from the chart and clinic personnel regarding insurance coverage and reason for the procedure.
Gathers information from the chart and clinic personnel regarding insurance coverage and reason for the procedure.
Relays authorization approval, peer to peer request or denial status to the clinic personnel and physician timely to facilitate patient care.
Accurately and efficiently processes referrals to specialists, hospitals and diagnostic centers in accordance with physician orders processing referrals in a timely manner for required services in the most appropriate setting; coordinates the referrals with insurance providers so that financial liability to the patient is minimized.
Obtains/scans outside clinic records after patient appointment with specialist to assure continuity of care.
Quality
Utilizes available resources to determine if physician is participating with patients’ insurance plan. Ensures lists of doctors and needed items are updated and modified as necessary.
Attends meetings as required and participates on committees as directed. Strives to improve the quality of meeting by taking an active role in meeting topics.
Assures that authorizations are obtained prior to date of service for 99 % of cases scheduled.
Schedules are reviewed prior to date of service to assure that authorization numbers have been obtained for all procedures that require one.
Scans authorization confirmation/denials into chart in a timely manner to facilitate claims processing should issues arise.
Financial
Responsible for the verification of insurance information, as well as documenting the need for authorization or lack of need for authorization in the computer system to facilitate claims processing.
Contacts insurance carriers to secure authorization information. Documents authorization information in the computer system to ensure visits are approved.
Acts as a resource for the department personnel as it relates to the authorization process and documentation required for services.
Other Duties as Assigned
Performs other duties as assigned or requested.
Experience: 1 year experience in medical office or hospital setting
Education: High School or equivalent
Special Skills: Basic clerical and computer skills