Function: |
| The Authorization Specialist is primarily responsible for securing prior authorizations for medical and behavioral health services by reviewing patient medical history, verifying insurance coverage, and confirming referral details with current and referring providers. This role ensures timely submission and follow-up on authorization requests, monitors the schedule for add-on patients to prevent conflicts, and confirms that all necessary approvals are in place prior to appointments or procedures. |
Organizational duties & responsibilities: |
- The primary responsibility of all staff is to ensure the safety and well-being of all Ramey-Estep/Re-group (RE) clients.
- Supports the mission, vision, and values of RE. Facilitates and adheres to the agency’s code of ethics, policies, and procedures.
- Supports all functions that attain and maintain accreditation and compliance with regulatory agencies.
- Supports and facilitates positive interaction with clients and staff by exhibiting both in-office and in-public when carrying out job duties: individual maturity, respect for others, a team-centered approach, maintenance of confidential information, and awareness and sensitivity to cultural and other differences in clients and staff.
- Exhibits effective communication skills, including proper use of agency communication systems.
- Participates in appropriate professional development programs to attain and maintain competency.
- Effectively manages financial and physical resources to achieve the mission of RE.
- Reports incidents of abuse or potential abuse involving clients to the appropriate authorities and RE.
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Essential Duties and Responsibilities: |
- Completes and submits prior authorizations, referrals, and precertification forms for services, appointments, and procedures per payer requirements.
- Reviews patients’ medical history and insurance coverage to determine authorization needs and obtain required approvals.
- Collects and uploads relevant medical documentation from the electronic health record (EHR) system to support authorization requests.
- Coordinates with providers, office staff, and referring physicians to gather additional clinical information, especially in denied authorizations.
- Schedules and facilitates peer-to-peer reviews between providers and payers when required.
- Monitors and follows up on submitted authorizations, documenting all communications and status updates.
- Enter authorization approvals and related information into the EHR to support accurate and timely billing.
- Notifies providers of approval determinations and ensures all necessary authorizations are in place before patient appointments or procedures.
- Conducts eligibility verifications for incoming and existing patients.
- Maintains and updates spreadsheets to track reauthorization or renewal dates, helping to prevent lapses in required approvals.
- Regularly reviews payer websites for updates to CPT codes and authorization policies and communicates relevant changes to the appropriate staff.
- Input new patient information and update existing records as needed.
- Monitors the patient schedule to identify potential issues related to authorization or eligibility and resolve conflicts proactively.
- Completes billing documentation accurately and promptly.
- Monitors incoming faxes, emails, and phone calls to ensure prompt receipt of authorization decisions and timely communication with payers.
- Assists with general clerical and administrative tasks to support the department.
- Participates in supervision and consultation regularly.
- Ability to be flexible and adapt to changes in schedules and work environment.
- Ensure all necessary records are maintained and kept confidential.
- Ensure entries in all treatment plans and narrative reports to MCOs are done professionally and concisely and will be submitted as needed to maintain a current authorization for services.
- Collaborate effectively with other RE services and community partners.
- Promotes a positive view of RE to the public and outside agencies.
- Performs other duties as assigned.
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Working conditions/environment: |
- Shift is generally Monday – Friday.
- Holidays, weekends, and extra hours may be required.
- Meals are provided for staff when on campus.
- Intense, unpredictable population with the possibility of verbal and physical aggression.
- Fast-paced environment with the need for quick decisions to deal with any crisis that may arise.
- Primary work setting is in the office.
- Maintains a positive, professional attitude contributing to a supportive work environment.
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minimum job requirements: |
Education: | A High School Diploma or equivalent is required.
An Associate’s Degree is preferred. |
Experience: | Prior experience in medical billing or insurance authorization is strongly preferred.
Knowledge of medical terminology is preferred. |
Specific Skills andrequirements: | Must be at least 21 years of age.
Must have strong leadership and organizational skills.
Must have excellent communication and conflict-resolution skills.
Technical requirements include proficiency with Microsoft Word, Excel, PowerPoint, and any other applications used by the organization or regulatory agencies.
Ability to understand and relate to the needs of clients from diverse backgrounds.
Ability to read, write, and converse in English.
Successful completion of a pre-employment drug screen.
Successful completion of a background screening.
Successful completion of a TB skin test or proof of a negative chest x-ray or other documentation. |
Specialized Licenses or training: | Maintains 20 hours of Annual Training through Relias or other appropriate sources.
Attends all assigned training specific to job assignment. |
Physical Requirements: |
The physical requirements described here are representative of those that an employee must meet to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions.
While performing the duties of this job, the employee is regularly required to stand, walk, talk, hear, and smell. The employee frequently is required to sit; use hands to finger, handle, or feel; reach with hands and arms; and stoop, kneel, crouch, and climb stairs. The employee is occasionally required to climb, balance or run. The employee must frequently lift and/or move up to 10 pounds or more. Specific vision abilities required by this job include close vision, distance vision, and peripheral vision. |
Supervisory REquirements: |
| N/A |
