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Insurance Authorization Specialist
Good Shepherd Rehab Philadelphia , PA 19107
Posted 2 weeks ago
* 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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Insurance Authorization Specialist
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