Authorization Specialist

Authorization Specialist, Center of Hope

Valley Health Partners, Allentown, PA

Job Summary:

Obtains benefits and authorizations for surgical procedures, diagnostic testing, medications, outgoing referrals, and other services as part of daily operations. Determines the authorization protocols for each health plan and performs billing duties to ensure proper and timely payment is received from insurance carriers and patients.

Qualifications:

Education:

• High School Diploma/GED with specialized training in insurance, coding, billing, or similar healthcare certificate programs. Associate's degree preferred.

Experience:

• 1 year in a healthcare setting with insurance verification/authorizations can be substituted in lieu of specialized training.

Skills Needed:

• Familiarity with billing procedures and payer reimbursement.
• Knowledge of patient rights and laws relative to those rights, such as HIPAA.
• Proficient in utilization management processes, standards, and managed care.
• Proficient in standard medical practices and insurance benefit structures

Essential Functions:

• Collaborates with physicians and provider office staff in ascertaining the appropriate authorization based on medical necessity and the treatment plan provided.
• Performs a medical necessity check to determine if procedure and diagnosis support medical necessity.
• Ensures authorizations are obtained in accordance to network policy (any authorization not falling into policy guidelines is communicated to ordering office, patient, and manager).
• Communicates direct/indirect with insurance companies to obtain insurance verification, benefits and precertification for approval.
• Verifies additional clinical information and insurance authorizations/referrals.
• Reviews and monitors WQs/schedules to ensure that proper and accurate authorization has been received prior to patient's visit.
• Maintains compliance with benchmark data regarding accounts registered versus scheduled procedures.
• Determines estimated patient financial responsibility using insurance verification information and payer contracts and/or self-pay guidelines.
• Takes on other duties as assigned
• Benefits:
• Choice of medical, dental, and vision plans with great coverage at VERY affordable rates.
• 403b Retirement Plan with generous company match
• Paid Time Off for holidays, vacation, sick & personal days
• Employee Assistance Program
• Tuition Reimbursement