Insurance Reviewer-Clinical

HOURLY RATE (DEPENDING ON SKILLS/EXPERIENCE): $22.00 - $27.00

SCOPE: The Authorization Specialist I is responsible for managng all aspects of the authorization process including responding to clinician requests within the established turn-around times set by the Auth Supervisor. Ongoing daily duties include collecting appropriate patient information from clinicians, working closely with insurance companies for approvals and tracking authorizations in process for timely completion. Manage appropriate prioritization as set forth by unit Supervisor for Emergency and Urgent requests. Effectively managing this process within the set guidelines is vital to the flow of patient care.

RESPONSIBILITIES:

• Prepare and submit request for authorization of services provided to our customers, including initial authorization, extension or subsequent authorization requests, within the established guidelines set forth by the Unit Supervisor.
• Track updated and timely status of authorization request with effective notes in referral, communication via email and/or in-basket when needed. Follow up with payer to ensure authorization is granted, paying close attention to authorization date spans and service codes.
• Provide timely follow up with clinicians and effectively communicate if/when additional information is needed to process the authorization request, appeal a denial or request peer to peer.
• Perform timely review of assigned WQs to ascertain next steps; prioritizing requests based on due date, stat, urgent, etc. Monitor and process external order WQs
• Review patient chart for MD orders to determine services/CPTs/HCPCs and reasons for requests and communicate timely and effectively with clinics to obtain any missing information needed to process referral.
• Enter authorized services into system and all detailed notes pertaining to phone calls, inbound and outbound, emails, in-basket, fax, web portal or any other way of communication, utilizing smart phrases when applicable.
• Work all assigned correspondence received via phone, email, in-basket, mail, scan or fax and provide communication for sites/providers via email, phone and/or in-basket
• Meet and maintain a 95% average or higher score on the established productivity minimum expectation set forth by the Auth unit supervisor.
• Meet and maintain a 95% average or higher score on the established quality audit score. Apply feedback provided and show timely improvement where necessary.

MINIMUM QUALIFICATIONS:

• High school degree or equivalent required
• Associates degree preferred
• Certificate Medical Billing or Insurance preferred
• 1-2 years experience in Healthcare Insurance in Medical / Hospital Environment required
• 1-2 years experience EMR required.

PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is required to be present at the employee site during regularly scheduled business hours and regularly required to sit or stand and talk or hear. Requires full range of body motion including handling and lifting patients, manual and finger dexterity, and eye-hand coordination. Requires standing and walking for extensive periods of time. Occasionally lifts and carries items weighing up to 40 lbs. Requires corrected vision and hearing to normal range.

WORK ENVIRONMENT: The work environment may include exposure to communicable diseases, toxic substances, ionizing radiation, medical preparations and other conditions common to an oncology/hematology clinic environment. Work will involve in-person interaction with co-workers and management and/or clients. Work may require minimal travel by automobile to office sites.