The Authorization Specialist is responsible for ensuring that payers are prepared to reimburse Riverview Health for scheduled services in accordance with the payer-provider contract. The Specialist contacts payers to request service authorization and may collect clinical, financial and/or demographic information from clinics, hospital departments and/or patients as needed.
Job Responsibilities
Verifies patients' insurance and benefits information
Obtains prior authorizations from third-party payers in accordance with payer requirements. Identifies patients who will need to receive Medicare Advance Beneficiary Notices of Noncoverage (ABNs).
Contacts patients to gather demographic and insurance information as needed, and updates patient information within the EMR as necessary.
Works with other departments to gather the clinical information required by the payer to authorize services. Maintains accurate records of authorizations within EMR.
Develops price estimates for patient out-of-pocket responsibility.
Refers accounts to financial counseling as needed if authorization is not obtained. Works with business office staff to support appeal efforts for authorization-related denials.
Reviews surgery schedules to ensure Medicare patients with IP-only procedures have the appropriate authorization and order.
Complies with HIPAA regulations, as well as Riverview Health policies and procedures regarding patient privacy and confidentiality.
Maintains professional tone at all times when communicating with patients and payer representatives.
Coordinates re-education to practices or hospital departments when orders are incorrect or not supported by the given diagnosis.
Performs other duties as requested.
Education Requirements
Minimum: Associate degree in healthcare or business administration and/or related coursework, or comparable experience
Preferred: Experience in Epic
Experience Requirements
Minimum: Two years of experience in a healthcare setting performing related tasks
Preferred: Five years of experience in a healthcare setting performing related tasks