The Authorization Representative is responsible for obtaining prior authorization from payers for inpatient and outpatient services. This role is key to securing reimbursement and minimizing organizational write-offs. The Authorization Representative must consistently demonstrate the use of critical thinking skills, skilled communication and troubleshooting techniques as well as have excellent customer service skills. The position requires the ability to independently complete prior authorizations both manually and through the use of system applications.
Qualifications:
- EDUCATION/EXPERIENCEREQUIRED – 2-5 years of experience in the Healthcare Revenue Cycle that includes prior authorization.
- Knowledge of CPT and ICD coding
- Knowledge of Medicare and third-party payer regulations and guideline KNOWLEDGE, SKILLS, AND ABILITIES
- Solid understanding and knowledge of payer contractual requirements, registration workflows, and prior authorization requirements to maximize reimbursement and minimize write-offs.
- Maintains current knowledge of medical modalities as well as new protocols established for patient populations.
- Understanding of payer medical policy guidelines while utilizing these guidelines to manage authorizations effectively
- Basic understanding of human anatomy, specifically musculoskeletal and neurology
- Proficient use of CPT and ICD-10 codes
- Able to meet productivity with 10 authorizations per hour with 95% accuracy.
- Excellent computer skills including Excel, Word, and Internet use.
- Detail oriented with above-average organizational skills.
- Excellent customer service skills; communicates clearly and effectively
- Ability to multitask and remain focused while managing a high-volume, time-sensitive workload
- Willingly accept feedback.
- Ability to problem-solve and work independently.
- Dependable and reliable in achieving goals.
- Familiarity with medical terminology and abbreviations
- US-based candidates onlyย
Responsibilities :
- Confirms the need for authorization and takes the appropriate actions to ensure the authorization is obtained.
- Verifies the basic patient/service information is available – the minimum data set for scheduling a service. If not present, initiates appropriate activity to obtain any needed demographic information from the client.
- Prioritizes the urgency of the authorization by anticipating the approximate time it may take to obtain the authorization from the insurance company, the complexity of the procedure, and the scheduled date of service; follows up with the insurance company to accelerate responses and expedite urgent/emergent authorizations.
- Understands the critical delineations of patient status (outpatient, inpatient, and observation) based on payor regulations.
- Escalates problematic (i.e., high-risk) admissions or any episode of service requiring additional attention.
- As needed, review medical policies to ensure that a case meets payer requirements. When unable to discern if a case meets the medical policy, will escalate the case appropriately to management.
- Communicate professionally and timely with internal and external customers.
- Provide helpful assistance in anticipating and responding to the needs of our customers.
