Authorization & Clearance Specialist, Days, M-F 2:00pm-6:00pm (Flexible on schedule)

Authorization & Clearance Specialist

Jackson Health System is a nationally and internationally recognized academic medical system offering world-class care to any person who walks through our doors. For more than 100 years, Jackson has evolved into one of the world's top medical providers for all levels of care, no matter if it's for a routine patient visit or for a lifesaving procedure. With more than 2,000 licensed beds, we are also proud of our role as the primary teaching hospital for the University of Miami Miller School of Medicine.

Here, the best people come together to deliver Jackson's mission for our diverse communities. Our employees are committed to providing the best CARE by demonstrating compassion, accountability, respect, and expertise in everything we do.

Responsibilities

• Identifies and confirms valid coverage for an episode of care and/or specific service: contacts insurance companies and/or reviews electronic response summary and coverage discovery information to ensure the appropriate coverage coordination are on the patient's record.
• Initiates authorization with patient insurance by submitting necessary clinical documentation, continues to follow up, obtain and validate authorization/referrals/notifications with appropriate CPT, ICD-10 codes, Tax ID and NPI #s within the appropriate timelines.
• Works daily work queues according to department directives, to identify patients requiring authorization for services scheduled and non-scheduled appropriately prioritizing work assignments based on scheduled appointment date/time, medical severity, payer assignments, dollar value etc.
• Verifies that the services the patient is set to receive is a covered benefit, validates benefit package restrictions, and completes quality assurance checks on authorization patient type, facility, etc.
• Understands patient deductibles, out of network referrals, out of pocket limitations, and lifetime/event caps on liability.
• Refers patients to appropriate Financial Counselor, Prior Authorization or Billing based on financial coverage, financial situation, employment status, liability and/or patient concern.
• Uses insurance discovery tools available to attempt to validate any and all insurance coverage, ensure correct insurance coordination of benefits are listed on patient's record, follows up with patient/next of kin/Social Work/Case Management in order to obtain insurance coverage information.
• Verify all insurance and obtain pre-certification/authorization for services, as warranted, and notifying patient and referring physician in the event of failed eligibility and/or authorization.
• Follows up with and escalates as appropriate to physician's office/clinical teams/Case Management for any pending clinical documentation, including peer-to-peer requests.
• Diligently follows up on any pending authorizations to ensure information is processed with the insurance payer within appropriate timelines.
• Works directly with JHS medical services to ensure procedures, diagnoses, level of care, are sufficient for each case by following CMS and payer guidelines and communicating with medical team for corrections.
• Maintain knowledge base of all programs offered by JHS for Charity and Financial Assistance and the requirements to qualify, with the process for Charity Care clearance of scheduled procedures and coverage.
• Calculates patients' financial responsibility based on patient benefits using the estimator tools and includes communication with the patients on the out of pocket due at service.
• Coordinate Self-pay Package pricing by utilizing tools available and escalating to Managed Care team to obtain appropriate package price amounts not found on list or complex contracts.
• Receives and processes all patient payments in accordance with JHS Collections Policy and Procedure, issues receipt and maintains the integrity of all payments.
• Scans/uploads all required documents into the appropriate folder in the documenting imagining system in a timely manner to assure maximum reimbursement and compliance.
• Assist in supporting go lives of new systems and different department initiatives, including onboarding and training team members.
• Cross-trained in multiple areas/service lines/payers to substitute all staff positions as needed.
• Demonstrates behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise). Performs other related job duties as assigned.

Generally requires 0 to 3 years of related experience. Financial clearance experience is strongly preferred.

High school diploma is required. Bachelor's degree in related field is strongly preferred.

Ability to analyze, organize and prioritize work accurately while meeting multiple deadlines. Ability to communicate effectively in both oral and written form. Ability to handle difficult and stressful situations with critical thinking and professional composure. Ability to understand and follow instructions. Ability to exercise sound and independent judgment. Knowledge and skill in use of job appropriate technology and software applications.

Valid license or certification is required as needed, based on the job or specialty.