Authorization Specialist (Full-time) at Billings Clinic in Billings, Montana

Job Description:

Responsible for performing the medication authorization functions with insurance carriers. Coordinate with/educate physicians, nursing staff and other health care providers on the authorization process and requirements. Works as a patient advocate and functions as a liaison between the patient, staff and payer to answer avoid care delays. Tracks, documents, and monitors authorizations. Implements check and balance systems to ensure timely compliance. Processes complete prescription claims including proper adjudication/reconciliation, insurance verification, prior authorization, and compassionate care/medication assistance programs associated with patient accounts and insurance claims billing.


Essential Job Functions


• Supports and models behaviors consistent with Billings Clinic's mission, vision, values, code of business conduct and service expectations. Meets all mandatory organizational and departmental requirements. Maintains competency in all organizational, departmental and outside agency standards as it relates to the environment, employee, patient safety or job performance.
• Coordinates medication authorization process ensuring authorization has been obtained.
• Identifies and initiates precertification/authorization requirements for individual payers and communicates with payer sources in a timely manner to obtain necessary pre-certification/authorization.
• Processes complete prescription claims including proper adjudication/reconciliation, insurance verification, prior authorization, and compassionate care/medication assistance programs associated with patient accounts and insurance claims billing.
• Enters medication charges and credits for the adjudication/reconciliation of patient accounts and insurance claims billing.
• Participates in quality improvement activities utilizing performance improvement principles to assess and improve quality.
• Documents and maintains patient specific precertification/authorization data within the required information systems. Documents and tracks authorizations using established process.
• Reports denials and/or delays in the precertification/authorization process to physicians/other health care providers and/or the patient.
• Develops and maintains collaborative working relationships with payers and health care team.
• Reports non-compliance issues to department specific leadership team.
• Works with Medical Staff Office validating provider enrollment and NPI numbers.
• Tracks and verifies that medication precertification/authorization has been received either verbally or written.
• Communicates status to health care team and patient as needed. Reviews schedules and work lists multiple times throughout the day.
• Reports medication denials and/or delays in the authorization process to the health care team and the patient. Provides information to the patient on the appropriate appeal process for denials as needed.
• Performs other duties as assigned or needed to meet the needs of the department/organization.


Additional Duties: Pre-certification


• Responsible for authorization of pre-scheduled elective outpatient procedures such as Botox injection procedures.
• Reviews CPT, HCPCS, and ICD-10 diagnosis codes against the National Coverage Determination (NCD) or insurance policies. Maintains updated list. Validates CPT and diagnosis codes match documented physician treatment plan.
• Participates in interdepartmental meetings to coordinate efforts, work through processes, and foster communication.
• Responsible for medication preauthorization and/or precertification for Billings Clinic campus


Additional Duties: Concurrent - Authorization


• Understands insurance/payer policy language, benefits and authorization requirements upon admission, for concurrent review, and for discharge.
• Coordinates Peer to Peer reviews. Submits letters of medical necessity and follows up on payer denial outcomes.
• Participates in continuing education, department planning, work teams and process improvement activities.
• Conducts follow-up calls, as necessary, to third party payers to complete authorization process validating that all days are authorized.
• Facilitates retro-authorization process with payers. Communicates outcome with patient, physician, Patient Financial Services and other key departments
• Responsible for coordinating resolution of varied problem situations and performing necessary investigation and research as it relates to the authorization process to resolve pre-certification/authorization problems.
• Works closely with Payer Relations coordinating needed pre-certification/ authorizations for in-network and out of network services.
• Maintains reference manuals that outline the individual payer requirements as it relates to precertification and authorization needs while also being responsible for the integrity and accuracy of the payer data.
• Responsible for the orientation and education of physician, nursing staff, who rely on the pre-certification process.
• Works with Coding Resources validating correct and billable CPT code, writes process with critical elements for new procedures and maintains pre-certification instruction manual.
• Reviews, updates and standardizes forms and processes as needed.
• Initiates workflow for new procedures/service lines.


MINIMUM QUALIFICATIONS


Education


• High school graduate or equivalent


Experience


• 2-3 years of experience in claims authorization work. Knowledge of coding preferred.