MEDICAL NECESSITY & AUTHORIZATION COORDINATOR

General Purpose of Job:

This role is responsible for obtaining financial authorization prior to services being received. The Authorization Coordinator works closely with insurance companies and clinical staff to secure payment prior to services, thereby increasing cash flow and reducing write-offs and bad debt. The accuracy of these tasks will ensure authorization for high revenue services and secure payment for the health system.

Essential Duties:

This job description is intended to cover the minimum essential duties assigned on a regular basis. Associates may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.

• Assess patient treatment and therapy plans to determine authorization requirements.
• Understands with working knowledge and payor requirements for obtanining authorizations.
• Develops relationships with clinical staff and physicians to secure payment for services related to patients therapy and treatment plans.
• Responsible for providing all required medical information to insurance companies as necessary to facilitate the authorization process.
• Works with specialty pharmacies to obtain authorization for prescription medications.
• Assist in educating and acts as a resource to clinicians and support staff regarding authorizations.
• Follow up on insurance determination within specified time frames.
• Coordinates resolution of escalated member or provider inquiries as related to prior authorization or denial of authorization.
• Communicates to clinicians or other medical staff regarding prior authorizations and pre-certifications especially if a medical procedure or medication has been denied authorization.
• Checks for medical necessity or works with operations to detgermine insurance requirements.
• Verify insurance eligibility and covered benefits by using all electronic systems available or by phone.
• Assist uninsured & under insured patients by screening for all available assistance programs, including community, state and federal programs, in order to secure payment for the hospital. Possess knowledge of financial class requirements with regard to registration and insurance requirements.
• Educate the patient as to their financial responsibility. Collect prepayment for hospital services that are not covered by the patient's insurance, including co-pays, deductibles, or good faith deposits.
• Operate multiple computer applications to register patients, retrieve insurance, financial information and review medical records.
• Serve as a liaison between Patient Access and other departments e.g. Patient Support Services, Pre-Service, Patient Financial Services, physician office staff, etc., in order to obtain required data or to escalate issues as necessary.
• Work exception accounts held internally or rejected by payers for errors related to authorization.