Insurance Verification and Authorization Specialist

GENERAL SUMMARY:

Responsible for verifying patient insurance and benefits and obtaining prior authorization for scheduled medical services and hospital admissions following payer-specific guidelines. Responsible for ensuring urgent/emergent cases are worked within one business day of admission and all elective cases worked prior to date of service.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Serves as work resource and liaison to hospital departments, physician offices, and patients for pre-service authorizations or financial responsibility questions.

3. *Adheres to federal regulations regarding Advance Directives, COBRA, Medicare, Corporate Compliance, Joint Commission, OSHA and HIPAA; reports safety and customer concerns.

4. Maintains productivity and quality standards as defined through the organizational and departmental goals and objectives.

5. *Verifies third party insurance coverage from daily admissions and scheduling databases; including contacting ordering physician's office for missing insurance and procedure information and updates appropriate software systems.

6. Facilitates authorization process with offices and providers.

7. Serves as work resource and liaison to hospital departments, physicians' offices, and patients for pre-service authorization or financial responsibility questions.

8. *Ensures that pre-certification and/or authorization and referral requirements have been completed by placing phone calls to insurance companies, physician offices, patients, and utilizing web based applications and/or internet resources; obtains clinical information from physician offices and/or Bryan system; contacts Health Information Management to obtain CPT and/or ICD-9 codes.

9. Submits patients supporting medical records and necessary information to payer authorization representatives for prior authorizations via fax, phone or online portals.

10. *Notifies Care Management when eligibility and/or benefits are complete on applicable admissions; notifies CM about Medicare Dental Carries patients.

11. Accurately and completely documents all actions taken regarding the prior authorization process including the authorization numbers, authorized dates and other applicable information in the applicable computer systems.

12. Maintains accurate payer website information and logins to ensure the most current information is obtained for the necessary authorization requirements.

13. Provides effective communication, proactively and in response, to patients/family members, team members, physicians and other healthcare providers while maintaining confidentiality.

14. *Supports the financial goals of Bryan Medical Center by communicating with patients and their insurance companies to obtain pertinent information about procedure reimbursements and patient responsibilities.

15. *Explains notice of non-coverage or offers to re-schedule elective tests and procedures, when patient's pre-authorization is not obtained; notifies patient and physician of outcome.

16. Prepare and provide patients with an estimate, if one is warranted, for their expected services and/or connect the patient/guarantor to the estimates team.

17. Communicates with Patient Financial Services regarding denials and appeals/reconsideration letters received from payers.

18. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

19. Participates in meetings, committees and department projects as assigned.

20. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk "*". Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed.

EDUCATION AND EXPERIENCE:

High school diploma or equivalency required. Associates degree preferred. Certified Medical Assistant or Licensed Practical Nurse preferred. Minimum of one (1) year of relevant work experience (i.e. hospital billing, coding or prior pre-authorization experience) preferred. Must be 19 years of age to witness legal consents.