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Authorization Specialist

4 months ago

Alpharetta, United States Restore First Health Full time

Restore First Health offers advanced care for chronic wounds, diabetes and metabolic disorders, non-invasive knee pain relief and physical therapy. We have multi-specialty practices in Georgia, New Jersey, Pennsylvania and Florida. Every member of our team plays an essential role to ensure we help make our patients better today and healthier tomorrow. Find your next career opportunity and make a difference doing what you love at Restore First Health.

The Authorization Specialist reviews insurance information and determines if any authorization or official confirmation is necessary before providing the medical services. The Authorization Specialist will also perform prior authorization responsibilities, which entail determining if the insurance company covers a given procedure or service. Additional duties are to compile paperwork related to the patient, assess their eligibility for services that Restore First Health provides its patients, communicate with the insurance provider, and track the progress of all referrals that require prior authorization. This position will report to the Senior Area Operations Manager and will cover all of Restore First Health's service lines at all clinics.

Required Minimum Education: High School diploma or equivalent. Medical coding and/or authorization training or education preferred.

Required Minimum Experience: Two years of experience performing verification of benefits and prior authorizations for medical services.

Required Minimum Skills: Computer literacy and advanced data entry skills. Experience processing/managing referrals or authorization requests in a Utilization Management department for 2 years, demonstrating production and accuracy well above the minimum required goals, or an equivalent combination of education and experience, which would provide the required knowledge, skills and abilities may also be qualifying.

  1. Authorization Processing:
    1. Assist in processing medical services requests. Completes clerical duties related to the processing of Authorization Requests and Provider Referrals.
    2. Inputs all requests for services received via fax or phone into the system accurately for electronically generated authorization and tracking.
    3. Provides services authorizations to providers per RFH Policy and Procedures and specific contracted Client's process on a timely manner.
    4. Requests submission of appropriate medical records according to established criteria for requested service(s) in accordance with the corresponding Policy and Procedure.
    5. Notifies required parties within the appropriate timeframe for routine and urgent requests for services.
    6. Researches member history for duplications and consideration of authorization limits.
    7. Verifies fax numbers and system updates. Communicates with requesting provider for any identified need to clarify a request for an authorization, such as CPT codes, ICD10, requested timeframes and member's demographics.
    8. Provides effective departmental communication with both internal and external sources.
    9. Forwards Authorizations to appropriate department staff in terms of eligibility and other coverage, pricing, and benefit issues.
    10. Scans, attaches, reviews and effectively works with electronic images as part of the authorization process. Including recording the required information from attachments into the authorization fields.
  2. Data Entry and Communication:
    1. Collaborates with Supervisor, Network and Claims Department Staff to resolve complex authorization issues.
    2. Appropriately forwards all referral requests to the next level of clinical review as applicable and after verifying for completeness and appropriateness.
    3. Coordinates approved outpatient surgical procedures in specialist's office and/or outpatient surgical facilities with health plan's authorization department when applicable.
    4. Coordinates approved services with clinic managers, providers, front office staff, and the Wound Care Coordination Manager.
    5. Is resource person for benefits and coverages and when insurance companies implement changes.
    6. Maintains appropriate logs, records, and reports as established by Utilization Department.
    7. Documents and communicates areas of concern to supervisor.
  3. Other duties:
    1. Serves as back up to verifying member's eligibility and benefits with subsequent notification to designated staff of eligibility issues.
    2. Adheres to company HIPAA policies and procedures. Identifying, maintaining and protecting sensitive HIPAA information (PHI) and following procedures to ensure the security of such information.
    3. Coordinates authorizations with appropriate billing personnel for claims processing.
    4. Assists with other clerical tasks as needed.

At Restore First Health, we are committed to providing a positive work environment that supports the well-being of every team member and supports a work/life balance. We believe in taking care of our team members so our team members can focus on providing the best care possible for our patients and the communities we serve. We offer very competitive pay, paid holidays, two weeks of paid time off, sick leave, 401k matching, tuition reimbursement and multiple insurance plan options.