Insurance Authorization Specialist

3 weeks ago

Philadelphia, United States Good Shepherd Rehabilitation Network Full time
  • JOB SUMMARY
      • Acts as a liaison with all insurance providers including commercial, managed care, and governmental plans
      • Gathers and submits patient information to secure prior authorizations for inpatient IRF and LTACH admissions
      • Gathers and transmits required documentation to the Medicare Administrative Contractor as required by CMS in the setting of demonstration projects and audits
      • Assures accuracy of authorizations including program identifiers and level of care
      • Communicates the need for peer-to-peer discussions and/or member appeals as necessary in the case of denied authorization requests
      • Researches authorization related denials, determines cause and resolution, and communicates with hospital billing for corrected claim submission
      • Acts as a patient advocate between the patient and their insurance plan
      • Provide support with verification of patient benefits and eligibility as needed
  • ESSENTIAL FUNCTIONS
    • PATIENT / CUSTOMER

      • Essential Accountabilities

        • Maintain compliance with HIPAA regulations.
        • Act as a patient advocate between the patient and the insurance plan.
        • Develop and maintain strong collaborative relationships with insurance providers.
        • Recognize time sensitive nature of obtaining prior authorizations.
        • Accurate and timely communication of authorization status to Clinical Liaison, Admission, and Case Management teams.
        • Conduct real-time and retrospective chart audits for CMS compliance.
        • Contributes to a positive work environment and to the overall efforts of the Patient Access and Case Management teams.
      • Non-Essential Accountabilities

        • Perform other duties in the scope of payer relations as assigned.
    • PATIENT/ EMPLOYEE SAFETY ACCOUNTABILITIES

      • Participates in Entity and Department wide initiatives for Patient /Employee safety.
      • Demonstrates an awareness of patient/ employee safety when carrying out daily responsibilities.
      • Regular validation of competencies as related to tasks required for the position.
    • OPERATIONS

      • Essential Accountabilities

        • Direct communication with Clinical Liaison and Admission teams to determine need for patient prior authorization via daily meetings, email, text and phone.
        • Obtain necessary demographic and clinical information to support prior authorization via PennChart, patient records, and with direct communication with Clinical Liaison and Admission team.
        • Maintain contact list for prior authorization and utilization management representatives with contracted insurance providers.
        • Secure prior authorizations for patient admissions via insurance provider portal and phone, or as directed by insurance provider.
        • Communicate status of authorization to Clinical Liaison, Admission, and Case Management teams in a timely manner.
        • Communicate the need for peer-to-peer discussions and/or member appeals as necessary in the case of denied authorization requests.
        • Investigate claim denials for authorization related issues, determine cause, and contact insurance provider for resolution.
        • Conduct real-time and retrospective chart audits as needed to determine compliance with payer regulations.
        • Verify patients' insurance benefits and eligibility for services via insurance provider portal and phone, or as directed by insurance provider, as needed.
        • Remains current with Managed Care and Payer Relations updates.
        • Remains current with CMS updates affecting the IRF and LTACH programs.
        • Partner with Penn Medicine and GSRN Managed Care teams to develop Single Payor Agreements (SPAs) as needed.
        • Verify prior authorizations are provided with the correct NPI and program identifiers for the IRF and LTACH programs.
        • Accurately record authorizations and related notes in the Electronic Medical Record for billing procedures.
      • Non-essential Accountabilities

        • Promotes available services of the GSPP IRF and LTACH.
        • Participates in GSPP unit-based committees as needed.
  • QUALIFICATIONS:
    • To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

      • Education
        • High School Diploma required
        • Associate's Degree preferred
      • Work Experience
        • 1 -2 years in health insurance authorization or verification process; hospital experience preferred
      • Licenses / Certifications
        • N/A

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