The Authorization-Referrals Specialist II is responsible for verifying insurance policy benefit information, and securing payer required referrals and authorizations.
Verifies insurance coverage via system tools, payer portals (Electronic Query (Real-Time-Eligibility [RTE]/Insurance Payer Portal/Phone).
Determines payer referral and authorization requirements for professional services.
Contacts patient and PCP to secure payer required referral for planned services. Documents referral in practice management system.
Researches system notes to obtain missing or corrected insurance or demographic information.
Reviews clinical documentation to insure criteria for procedure meets insurance requirements.
Initiates authorization and submits clinical documentation as requested by insurance companies.
Communicates with surgical coordinators regarding authorizations status or denials.
Submits appeals in the event of denial of prior authorizations or denial of payment following procedures.
Calculate and document patient out of pocket estimates and provide to patient.
Responsible for being a specialist in the area of payer policy authorizations for internal and external customer inquiries.
Serves as primary liaison between faculty practice/department, insurance companies and patient to verify eligibility and coordination of benefits and resolve any insurance complications.
High school graduate or GED certificate is required.
A minimum of 2-years experience in a physician’s billing or third payer environment.
Candidate must demonstrate the ability to understand and navigate managed care eligibility, insurance billing requirements, and obtaining pre-authorizations.
Candidate must demonstrate a strong customer service and patient focused orientation and the ability to communicate, adapt, and respond to complex situations. Including the ability to diffuse complex situations in a calm and professional manner.
Must demonstrate effective communication skills both verbally and written.
Ability to multi-task, prioritize, document, and manage time effectively.
Functional proficiency in computer software skills (e.g. Microsoft Word, Excel and Outlook, E-mail, etc.)
Functional proficiency and comprehension of medical terminology.
Ability to work independently and collaborate in teams.
The ideal candidate is a motivated individual with a positive attitude and exceptional work ethic.