Authorization Specialist
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Overview
Job Description
Job Summary
The Authorization Specialist is responsible for ensuring that payers are prepared to reimburse Riverview Health for scheduled services in accordance with the payer-provider contract. The Specialist contacts payers to request service authorization and may collect clinical, financial and/or demographic information from clinics, hospital departments and/or patients as needed.
Job Responsibilities
- Verifies patients' insurance and benefits information
- Obtains prior authorizations from third-party payers in accordance with payer requirements. Identifies patients who will need to receive Medicare Advance Beneficiary Notices of Noncoverage (ABNs).
- Contacts patients to gather demographic and insurance information as needed, and updates patient information within the EMR as necessary.
- Works with other departments to gather the clinical information required by the payer to authorize services. Maintains accurate records of authorizations within EMR.
- Develops price estimates for patient out-of-pocket responsibility.
- Refers accounts to financial counseling as needed if authorization is not obtained. Works with business office staff to support appeal efforts for authorization-related denials.
- Reviews surgery schedules to ensure Medicare patients with IP-only procedures have the appropriate authorization and order.
- Complies with HIPAA regulations, as well as Riverview Health policies and procedures regarding patient privacy and confidentiality.
- Maintains professional tone at all times when communicating with patients and payer representatives.
- Coordinates re-education to practices or hospital departments when orders are incorrect or not supported by the given diagnosis.
- Performs other duties as requested.
Education Requirements
- Minimum: Associate degree in healthcare or business administration and/or related coursework, or comparable experience
- Preferred: Experience in Epic
Experience Requirements
- Minimum: Two years of experience in a healthcare setting performing related tasks
- Preferred: Five years of experience in a healthcare setting performing related tasks
License/Certification Requirements
- None
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