Job Details

Description

Job Summary: The position of the Authorization Specialist coordinates the utilization review and appeals process as part of the denial management initiatives. This position is responsible for coordinating phone calls, data entry and tracking data from various insurance providers and health plans regarding authorization, expedited reviews and appeals. Document and track all communication attempts with insurance providers and health plans. This position will follow up on all denials while working closely with the Corporate/Facility Utilization review teams, Business Office, and Case Managers. This position will also serve as the primary contact and coordinate the work to maintain integrity of tracking government review audits (RAC, MAC, CERT, ADR, Pre/Post Probes, QIO/Medicaid) and other payer audits as assigned. This position will further support the department needs for Release of Information, discharge coordination or other duties as assigned.

This position supports the Pipeline Health Culture Club Values through the provision of distinctive and compassionate care to our employees and patients. Actively and consistently contributes to department operations and communications, behaves in a manner consistent with the mission, vision, and values of Pipeline Health, upholding standards of AIDET (Acknowledge, Introduce, Duration, Explanation, Thank you) patient communication.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.

Essential Funcations:

Maintain confidentially, protecting patient information always: minimum information necessary to those with right and need to know. Abides by HIPAA (Health Insurance Portability and Accountability Act) regulations.
Coordinate all denials and appeal correspondence. Develop training and education for issues identified in RAC and authorization. Conducts oversight of all denial management functions. Follow all denials/ appeal activity to closure.
Maintains data base for tracking denials, reason, appeals, and outcome of appeals. Track status of all appeal activity using automated tracking system.
Verifies each page of the record is in the appropriately labeled folder by patient name, MRN, & volume number, in assuring a complete, legal medical record. Accurately accesses the completeness of the legal medical record.
Collects, analyzes, aggregates, and presents data accurately.
Reviews medical records and other documentation to prepare Appeals packages.
Communicate and coordinate with various individuals/distributions and assist with the management of the day to day activities related to Government Audit Reviews, denials, and appeals. Open communication between Corporate Team and Administration/ CFO, Business Office/ Financial Services, Case Management/ Physician Advisor. for clinical Review, RACs/ CMS.
Collect/analyze, report status, metrics, and trends of activity by different reviews from tool. Distribute reports on a routine basis to specific distribution group. Coordinate the RAC Committee with reports to Corporate compliance.
All Audits are to be kept in an organized retrievable way and electronically scanned and filed.
Performs as a liaison, assisting medical staff members in accurate & timely chart completion through collaborative methods.
Assist with coordination of Gov't Review Audits (RAC) Committee activities and materials for committee meetings, including agenda, dashboards, analyses, reports, etc.
Responsible for the communication of all new policy's, memorandums, and processes from department and/or governmental payers for all review audits.
Maintain integrity of Denials/Appeals database and assist in financial reporting of activity. Invoice submitted record requests, if applicable.
Responsible for review/analyze audits and insurance denial letters that are received and the validity of findings of various audit contractors.
In the event findings are incorrect, position responsible for communicating with audit contractors/insurance CM for correction and submitting evidence.
Develop Internal Training Programs. Other functions outside of RAC function such as clinical review, clerical/ administrative support for RAC tracking system data entry, Release of Information (ROI) process/ function.
Effective communication: writes and speaks clearly and concisely, affecting positive and efficient assistance to all requestors.
Obtain authorization pre-& post billing.
Review and work in-house patients off the census report.
Fax information to health plans, IPA’s & medical groups as needed to obtain authorizations.
Communicate directly with case management on problem accounts.
Learn and utilize financial, imaging, and clinical systems pertaining to job.
Work accounts that fall on the CRC report up to 10 days after discharge.
Enter in authorization numbers on hospital financial system so bills can drop.
Scan hard copy authorization into imaging system.
Document financial system appropriately and timely.
Knowledge of Microsoft Excel to create spreadsheets on pending authorizations.
Reviews and updates accounts with correct payor codes and addresses.
Communicates with CBO nurses on retro & clinical appeals.
Follow up with Payers for claim numbers so appeals can be sent out timely.
Tag accounts appropriately on authorizations denied appearing on CBO worklist.
Knowledge of hospital contracts and terms for authorization request.
Perform required tasks and other duties as assigned, while maintaining a positive attitude.
Completes job duties in accordance with productivity requirements and quality standards.
Promptly report equipment malfunctions to the appropriate personnel to order service as needed.
Performs all other duties and special projects as assigned.
Completes and attends monthly training assigned.

Behavioral Standards:

Serves as a model to fellow hospital employees in confidentiality.
Regularly attends department meetings and in-service training programs to remain aware of pertinent developments and/or changes in related policies, procedures, and systems.
Independently recognizes and performs duties which need to be done without being directly assigned. Establishes priorities; organizes work and time to meet them.
Recognizes and responds to priorities, accepts changes and new ideas. Has insight into problems and the ability to develop workable alternatives.
Respectful of and responds to patients’ preferences, values and needs.
Exhibits customer and service-oriented behaviors in everyday work interactions.
Demonstrates a courteous and respectful attitude to internal workforce and external customers.
Communicates accurately and appropriately.
Works well and efficiently under minimal supervision.
Handles difficult situations in a discreet and professional manner.
Is adaptable to changes in assignments and priorities.

Communication/Knowledge:

Demonstrates knowledge of basic medical terminology related to performance of job duties.
Demonstrates working knowledge of terminal digit filing systems and concepts of unit records.
Comprehends and adheres to industry standards and regulatory requirements: including, but not limited to, TJC, HFAP, CMS, accreditation standards, regulatory requirements, HIPAA and hospital policies.
Demonstrates knowledge of all types of payer systems, i.e. authorization process and timely submission, including but not limited to Medicare and Medicaid. Assists CM in obtaining insurance and other related information.
Demonstrates ability to accurately and efficiently utilize the hospital information system and MPI print-out to research a medical record number.
Working knowledge of State and Federal standards for medical staff documentation.
Working knowledge of PHSI’s Medical Staff Rules & Regulations documentation requirements.
Demonstrates working knowledge of information systems related to job duties.
Possesses an awareness of hospital processes, location of departments, convenience areas, and other related patient/visitor services.
Wears nametag properly; follows dress code policy; answers phone correctly and promptly; is prepared for meetings; meets deadlines; does not participate in gossip; acts ethically and treats others with respect; respects customer’s and co-worker’s time; establishes and maintains effective relationships with customers and co-workers.
Provides accurate and timely written and verbal communication of information in a manner that is understood by all.
Able to listen, understand, problem-solve, and carry-out duties to ensure the optimal outcome.
Able to use IT systems in an accurate and proficient manner.

Collaboration/Teamwork:

Regularly consults with supervisor on areas of further instruction that would be beneficial and discusses any pertinent issues.
Accepts constructive criticism in a positive manner.
Is a team player and communicates effectively at all levels.
Contributes toward effective, positive working relationships with internal and external colleagues.
Demonstrates cooperation, flexibility, reliability, and dependability in all daily work activities and a willingness to collaborate with others for the good of the customer and the organization.

Qualifications/Experience:

Minimum one (1) year of denials management experience in acute care setting highly preferred.
Accurate alphabetic, numeric, and/or terminal-digit filing skills.
Computer data entry with 10-key, with accurate typing speed of 35 wpm required. Excel skills highly preferred.
Background in business and office training; preferred.
Knowledge of terminal digit filing and medical terminology; preferred.
Knowledge of State and Federal regulatory requirements for medical staff documentation; preferred.

Education:

Completion of a medical terminology course; preferred.

Licensure/Certifications:

AB508 Workplace Violence Prevention-Part 1, due within 30 days from hire date.

Qualifications

Experience

Required

2 years:

Minimum 2 years of experience in Managed Care

Pipeline Health System jobs

Authorization Specialist