Authorization Specialist

Job Summary

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

License/Certification Requirements

• None