Authorization Representative

Job Details
Coordinates insurance benefits verification and secures prior authorizations for surgical procedures, diagnostic testing, medications, referrals, and related services. Interprets payer-specific authorization requirements and ensures compliance with health plan protocols. Supports revenue cycle operations by performing functions that promote accurate claims submission and timely reimbursement from insurance carriers and patients.

Job Description

Summary
Coordinates insurance benefits verification and secures prior authorizations for surgical procedures, diagnostic testing, medications, referrals, and related services. Interprets payer-specific authorization requirements and ensures compliance with health plan protocols. Supports revenue cycle operations by performing functions that promote accurate claims submission and timely reimbursement from insurance carriers and patients.

Job Duties

• Collaborates with physicians and provider office staff in secure the appropriate authorization, referral based on medical necessity and the patients' treatment plan.
• Performs medical necessity review to ensure procedures and diagnoses meet payer requirements.
• Obtain authorizations in compliance with network policies and communicates any exception to ordering office, patient, and manager).
• Interfaces with insurance companies, both directly and indirectly, to verify coverage, benefits and obtain precertification.
• Reviews and verifies additional clinical information, insurance authorizations and referrals as needed.
• Monitors work queues and patient schedules to ensure accurate authorization are in place prior to each visit.
• Maintains compliance with benchmark metrics for accounts registered versus scheduled procedures.
• Calculates estimated patient financial responsibility using insurance verification, payer contracts, and self-pay guidelines. and/or self-pay guidelines.

Minimum Qualifications

• High School Diploma/GED
• 1 year experience in healthcare insurance verification, prior authorization requirements, and insurance benefits structures.
• Experience working with multiple insurance payers and understanding medical necessity requirements.
• Priorexperience working with electronic health record (EHR) systems and insurance portals.
• Familiarity with clinical documentation and interpretation of treatment plans.
• Knowledge of CPT, ICD-10 and HCPS coding as it relates to authorizations
• Knowledge of patients right and laws relative to patients rights such as HIPPA

Preferred Qualifications

• Associate's Degree in health administration, healthcare management or related field preferred.

Physical Demands
Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Work Shift
Workday Day (United States of America)

Worker Sub Type
Regular

Employee Entity
Thomas Jefferson University
Primary Location Address
1200 Old York Road, Abington, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.


Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.


Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

For more benefits information, please click here