Job Summary: The Authorization Specialist is responsible for performing complex clerical procedures related to verifying insurance information and obtaining authorization for inpatient admissions and specialized clinical procedures and treatments in accordance with established rules, procedures, specified time frames, and regulatory requirements.  The Specialist processes clinical information in a timely manner to prevent treatment delays and to avoid denials from third party payers and maintains confidentiality of patient information.

                Responsibilities: 

• Enters and retrieves information from various automated systems and prepares specialized reports.

• Perform telephonic clinical reviews to Behavioral Health Managed Care Organizations in order to obtain ongoing authorization.

• Ensure completion of Medicare Physician Certification according to regulatory timeline.
• Collects demographic and insurance data and enters accurately into specialized automated systems.

• Prepares, reviews for completion, and maintains required documents in accordance with established procedures, time frames and regulatory requirements.
• Makes contact to obtain missing information for incomplete forms.
• Advises clinical staff of problems with insurance authorizations and resubmits requests with additional or revised information.

• Contacts insurance providers to confirm level of benefits for inpatient admissions.
• Responds to customer inquiries and provides information.
• Serves as liaison between the clinical case management department and Patient Registration.

• Follows up with patient accounts department for accuracy of insurance change.
• Communicates with case managers, hospital personnel, and external agencies to provides information or resolve discrepancies.

• Document all inpatient authorization via Allscripts system for proper claims processing.
• Document all inpatient denials and schedule peer to peer review for physician advisor.
• Process expedited appeals as needed for inpatient admission denials.
• Initiate and follow-up on post-acute authorizations.
• Complete discharge logs for each insurance payor for proper utilization management processing.
• Utilize payor portals for authorization tracking and upload of inpatient utilization clinical reviews for approval of inpatient admissions.
• Manage high volume phones calls for the case management department.
• Manage high volume mail.
• Manage high volume of e-fax work queue.
• Scan all inpatient approval and denial letters into Allscripts system.
• Rotate weekends authorization staff coverage (new as per Huron).
• Maintain updated insurance contact for the clinical case management team

Qualifications:

Experience:

• Two to three years of clerical experience in health care field or related area required, with preference to behavioral health experience, preffered.

Education:  

• High school diploma or equivalency required,
• Associates Degree, preferred

Licenses / Certifications: N/A