Authorization Specialist

City/State:
West Nyack, New York
Department:
Highland CBO
Work Shift:
Day
Work Days:
MON-FRI
Scheduled Hours:
8:30 AM-5 PM
Scheduled Daily Hours:
8.5 HOURS
Scheduled Weekly Hours:
40
Hourly Rate/Range:
24.00

For positions that have only a rate listed, the displayed rate is the hiring rate but could be subject to change based on shift differential, experience, education or other relevant factors.

A.    Job Summary: Acts as a liaison between healthcare providers, insurance carriers and patients to verify coverage eligibility, obtain pre-certification for treatments and radiologic imaging studies. Schedule, reschedule, or cancel imaging exams. Clearly communicates procedure instructions, exam preparation requirements, and location directions to patients. Monitors the status of pending authorizations, communicate with payer case managers to expedite approvals and ensure required timelines are met.  Initiates and coordinates peer-to-peer reviews or appeals for authorization denials.  Accurately updates EPIC with authorization numbers, visit limits and expiration dates.  Educates patients and providers on coverage limitations or out of pocket costs. Works well as part of a team supporting the maintenance of a well-organized and friendly work environment.  Assists office front end staff with urgent eligibility and pre-authorization functions as necessary.  Communicates with Practice Managers when necessary to help in facilitating authorizations timely.

B.    Essential Job Qualifications

1.     Education:  High School Diploma or equivalent required.

2.     Experience:  One years’ experience preferred in a healthcare environment or a medical office or hospital setting. A general understanding of medical office procedures, billing, insurance carriers including Medicare and Medicaid preferred.  Must have experience working with computers; an electronic health record system; EPIC preferred.

3.     Training/Certification:  N/A

4.     Licensure:  N/A

5.     Other:  High attention to detail, persistence in dealing with insurance call centers, and strong problem solving and communication skills. Proficiency and working knowledge of EPIC and Microsoft Office.  Must be thorough when documenting information in an electronic health record.

B.    Job Specific Contacts

1.     General Contacts: Patients and family members, physicians, physician extender(s), insurance representatives and employees.

C.    Environment and Demands

Environmental Demands: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. While performing the duties of this job, the employee is occasionally exposed to fumes or airborne particles, radiation, and exposure to infectious diseases. The noise level in this environment is usually moderate.

Essential Physical and Cognitive Demands, Manual Dexterity: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation will be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job the employee is occasionally required to stand; sit; walk; use hands to finger, handle, or feel objects, tools, or control; reach with hands and arms; and stoop, kneel, crouch, or crawl. The employee must occasionally lift and move up to 50 pounds. Specific vision abilities required by this job include close vision. Some irregularity in scheduled hours because of compensated overtime requirements.  Weekend/Holiday rotation required.

Part I: Demonstrates adherence to Highland Medical, P.C. Standards:

A.   Organizational

W orking Together

·         Demonstrates the ability to work together with employees

·         Demonstrates courtesy and respect in all customer interactions

·         Demonstrates a positive spirit of service

E mpowerment

·         Demonstrates use of self-directed communication and decision-making

·         Demonstrates effective problem-solving skills

·         Demonstrates accountability for own words and actions at all times

·         Demonstrates ability to complete work responsibilities/projects in a thorough and timely manner

C ommunication

·         Demonstrates positive communication in all interactions

·         Demonstrates professionalism and courtesy in all interactions

A ppearance

·         Demonstrates personal pride in appearance

·         Demonstrates compliance with dress code

·         Demonstrates assistance in maintaining a clean, clutter-free environment

R esponsiveness

·         Demonstrates ability to provide timely feedback/communication to patient, visitor, or co-worker

·         Demonstrates effective problem-solving to point of resolution for customer

E xcellence in Service

·         Demonstrates ability and desire to exceed customer (internal or external) expectations within job requirements

·         Demonstrates positive outcomes in all aspects of job requirements

B.    MISSION/STRATEGIC PLAN:

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Participates in activities which support the mission of Highland Medical, P.C.

C.   JOB SPECIFIC COMPETENCIES:

1.     Authorization Submission:  Initiate, submit, and track prior authorization and pre-certification requests for office visits, surgeries, imaging (MRI/CT), therapies, and specialized medications.  Strong working knowledge of EPIC EMR System, medical terminology and managed care regulations.

2.       Insurance Verification:  Reviews and communicates with insurance policies, benefits, and coverage limitations using payer portals (e.g., Availity, NaviNet) to ensure all procedures align with industry guidelines.

3.       Documentation Management: Collect medical records, lab results, and letters of medical necessity from healthcare providers to substantiate authorization requests.

4.       Denial and Appeal Management: Track denied requests, identify denial trends, submit peer-to-peer reviews, and prepare formal appeals with supporting clinical evidence.

5.     Appointment Coordination:  Schedule, reschedule, or cancel imaging exams.

6.     Patient Communication:  Clearly communicate procedure instructions, exam preparation requirements, and location directions to patients.

7.     Performs all other duties as assigned.
Highland Medical, P.C. is an equal employment opportunity employer. Highland Medical, P.C. will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law.