Authorization and Denial Supervisor

4 weeks ago

Albany, United States St. Peter's Health Partners Full time

**Employment Type**:
Full time

**Shift**:
Day Shift

**Description**:
**Authorization and Denial Supervisor**

**Summary**

This position is responsible for oversight of authorization and denials within assigned service line ensuring appropriate prior authorization for related services, drugs, treatments, and supplies. Assists in the identification, reporting and resolution of any issues stemming from or with authorization and denial processes. Using data, system reports, and analytics, supports the needs of the authorization team. Instrumental in developing and implementing strategies to optimize all aspects of authorization and denials supporting the revenue integrity team through a comprehensive approach. The scope of prior authorizations may include (but is not limited to) consults, diagnostic testing in office procedures and pharmaceuticals including off label drugs, and drugs for clinical trials.

**Job Duties and Responsibilities**
- Leads efforts to ensure staff are properly trained, on-boarded, and regularly evaluated on competencies and quality of work.
- Leads oversight of appeals denied claims for elated services, drugs, treatments and supplies.
- Obtains and ensures timely prior authorizations for related services, drugs, treatments, and supplies according to care plan as outlined by provider.
- Assists interdepartmental teams in troubleshooting accounts that are being held in A/R due to lack of prior authorizations.
- Facilitates communication with care team and providers
- Appeals denied authorizations for related services, drugs, treatments, and supplies.
- Research denials and provide additional supporting documentation to appeal decision.
- Communicates appeal decision with care team and obtains additional required documentation to ensure claim is paid.
- Identifies opportunities and participates in optimization of EHR to track and submit authorizations to payors.
- Partners with leadership to educate providers and clinical staff on payor policy changes as it relates to administration of treatments (i.e. place of service requirements, coverage criteria changes).
- Prepares accurate reports and provides departmental summary information to Revenue Cycle Team and leadership that ensures all infusions and laboratory testing performed in the department are reviewed and prior auth or predetermination is obtained.
- Contributes to the effective management of the department.
- Demonstrates dependability on the job by adhering to departmental performance standards guidelines and attendance standards.
- Contributes to the time management of the department and respects fellow employees by being punctual to scheduled meetings and to work, starting work promptly, and adhering to scheduled hours and departmental performance standards guidelines.
- Works collaboratively and supports efforts of team members.
- Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community.

**Qualifications**
- Associate Degree and one to two (1 - 2) years of similar healthcare experience required, or, in lieu of Associate's Degree, a high school diploma/GED and five (5) or more years of similar healthcare experience will be considered.
- Preferred certification in CCS, CCS-P, CPC, or specialty coding.
- Three to five years’ experience in a health care environment with exposure, preferably in an environment with knowledge of the patient population and types of services patients receive.
- Prior authorization experience involving drugs and ancillary testing desirable.
- Knowledge of managed care and third-party payer benefits designs and reimbursement requirements.
- Knowledge of ICD-9 and ICD-10 coding and documentation requirements.
- Preferred experience in Epic or comparable EMR system
- Strong analytical skills with attention to detail and high degree of accuracy to produce reports, analyses, and other details as requested.
- Strong communication skills and attention to detail. Knowledge of drug regimens and associated regulations/policies/procedures applicable to insurance coverage and the associated payment for and appeal of procedures/billing rejected.
- Two years of experience in reviewing medical records for National Coverage Determinations (NCD) and local Coverage Determinations (LCD)
- A strong understanding of HIPAA laws and requirements as they relate to review and reporting of documentation.

**Pay Range:$25.85 - $37.50**

Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.

**Our Commitment to Diversity and Inclusion**

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and incl

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