Insurance Authorization Specialist

Job Title

Insurance Authorization Specialist

FLSA

Non-Exempt

Reports to

Manager, RCM

Grade 

E

Location

Remote

Band

1B

Description of Position:

Provide a “snapshot” or the principal purpose or focus of the position, consisting of no more than three to five sentences.  This summary should provide enough information to differentiate the major function and activities of the position from those of other positions.

Obtains insurance eligibility, benefits, authorizations, pre-certifications and referrals for inpatient and outpatient, scheduled and non-scheduled visits.  Updates demographic and insurance information in system as needed.  Primary documentation source for access and billing staff.  Resolve accounts on work queues.  Work with insurance companies to appeal denials.  Interacts in a customer-focused and compassionate manner to ensure patients and their representatives needs are met. 

Essential Functions/Responsibilities:

Essential functions are the duties and responsibilities that are essential to the position (not a task list).  o not include if less than 5% of work time is spent on this duty.  Be specific without giving explicit instructions on how to perform the task.  Do not include duties that are to be performed in the future.  Duties should be action oriented and avoid vague or general statements. 

% of Time

(annually)

Insurance Verification/Certification

• Obtains daily work from multiple work queues to identify what is required by CBO.

• Work with providers to assure that CPT and ICD-10 code is correct for procedure ordered and is authorized when necessary.

• Completes eligibility check and obtain benefits though electronic means or via phone contact with insurance carriers or other agencies and when necessary/requested provide initial clinical documentation.

• Initiates pre-certification process with physicians, PHO sites or insurance companies and obtains pre-cert/authorization numbers and adds them to the electronic health record and other pertinent information that secures reimbursement of account.

• Perform follow-up calls as needed until verification/pre-certification process is complete

• Thoroughly documents information and actions in all appropriate computer systems

• Notify and inform Utilization Review staff of authorization information to insure timely concurrent review 

• Validates or update insurance codes and priority for billing accuracy. 

• Works with insurance companies to obtain retroactive authorization when not obtained at time of service. 

• Works with insurance companies, providers, coders and case management to appeal denied claims.

• Responsible for following EMTALA, HIPAA, payer and other regulations and standards.

• Responsible for meeting daily productivity and quality standards associated with job requirements.

75%

Customer Services

• Adheres to department customer service standards. 

• Perform research to resolve customer problems

• Collaborate with other departments to assist in obtaining pre-authorizations in a cross functional manner

• Develop and implement prior authorization workflow to meet the needs of the customers.   

• Readily identifies work that needs to be performed and completes it without needing to be told.

• Coordinates work to achieve maximum productivity and efficiencies

• Monitors and responds timely to all inquiries and communications.

15%

Basic UPH Performance Criteria          

• Demonstrates the UnityPoint Health Values and Standards of Behaviors as well as adheres to policies and procedures and safety guidelines.

• Demonstrates ability to meet business needs of department with regular, reliable attendance.

• Employee maintains current licenses and/or certifications required for the position.

• Practices and reflects knowledge of HIPAA, TJC, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.

• Completes all annual education and competency requirements within the calendar year.

• Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse.   Brings any questions or concerns regarding compliance to the immediate attention of hospital administrative staff.   Takes appropriate action on concerns reported by department staff related to compliance.

10%

Disclaimer: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee.  Other duties, responsibilities and activities may change or be assigned at any time with or without notice.

Demonstration of UPH Values and Standards of Behaviors

Consistently demonstrates UnityPoint Health’s values in the performance of job duties and responsibilities

Foster Unity:

• Leverage the skills and abilities of each person to enable great teams.

• Collaborate across departments, facilities, business units and regions.

• Seek to understand and are open to diverse thoughts and perspectives.

Own The Moment: 

• Connect with each person treating them with courtesy, compassion, empathy and respect

• Enthusiastically engage in our work.

• Accountable for our individual actions and our team performance.

• Responsible for solving problems regardless of the origin.

Champion Excellence:

• Commit to the best outcomes and highest quality.

• Have a relentless focus on exceeding expectations.

• Believe in sharing our results, learning from our mistakes and celebrating our successes.

Seize Opportunities:

• Embrace and promote innovation and transformation.

• Create partnerships that improve care delivery in our communities.

• Have the courage to challenge the status quo.

Minimum Requirements

Identify items that are minimally required to perform the essential functions of this position.

Preferred or Specialized

Not required to perform the essential functions of the position.

Education:

Requires minimally a High school diploma or GED. 

Two years of experience in a hospital patient access/patient accounts department, medical office/clinic or insurance company is desired. 

Experience:

• Previous customer service experience.

• Experience interacting with patients and a working knowledge of third party payers.

• Prior experience with verification, and payer benefit and eligibility systems is preferred.

License(s)/Certification(s):

Valid driver’s license when driving any vehicle for work-related reasons.

Knowledge/Skills/Abilities:

• Ability to perform a variety of tasks, often changing assignments on short notice.

• Must be adept at multi-tasking

• Will be required to learn and work with multiple software/hardware products (sometimes concurrently) during the course of an average work day

• Must possess excellent communication skills, verbal and listening.

• Must be able to maintain a professional demeanor in stressful situations. 

• Adept with machinery typically found in a business office environment.

• Mathematical aptitude to make contractual calculations and estimate patient financial obligations.

• Able to build productive relationships with all contacts.      

• Must be able to perform data entry with speed and accuracy

• Knowledge of Medical Terminology is preferred.

• Knowledge of benefits and language is preferred.

Other:

Use of usual and customary equipment used to perform essential functions of the position.