Authorization Specialist

Work Shift Day (United States of America) Job Summary The Patient Access Services (PAS) Prior Authorization Specialist III position reports to the PAS Manager of Pre‑Service Operations and is responsible to secure accounts by performing a combination of insurance verification to gather benefit information if not already obtained and validating prior authorization has been initiated with the payer before services are rendered. This position works with physicians, nurses, clinic managers and financial advocates to resolve issues that arise during the prior authorizations process. This position may also support Pre‑Registration including preparing patient estimates. Maintain established productivity benchmarks and meets goals in a fast‑paced environment. Other duties as assigned. Core Responsibilities And Essential Functions Quality/ Safety Works in conjunction with Insurance Verification Specialist to verify insurance eligibility, benefits, network status and creates pre‑service liability estimate. Ensures accurate ICD, CPT codes and related medical records are submitted in the authorization request. Secures prior authorizations for scheduled and nonscheduled services. Acts as a liaison between the payer and clinic schedulers/medical support staff. Follows up on delayed or denied authorization requests and escalates for resolution. Creates detailed documentation and maintains/stores the authorization paper/electronic trail. May work in the work queues to resolve claims denials related to the prior authorization. Perform other work‑related duties as requested/directed by management. Observes work hours and provides proper notice of absences, tardiness, or work schedule changes. Maintains courteous and cooperative working relationships with WHS management, patients, physicians, other professional contacts, and the public. Demonstrates ability to tactfully handle difficult situations. Presents a well‑groomed and professional image. Documents thorough explanatory notes on patient accounts, concerning any non‑routine circumstances, clarifying special billing processes. Maintains a working knowledge of available information system capabilities and performs all system applications that are required. Understands and applies WHS philosophy and objectives, and PAS policies and procedures, as related to assigned duties. Understands the admission, outpatient and emergency registration process. Maintains confidentiality of patient information, in accordance with WHS policy and HIPPA regulations. Consistently demonstrates the ability to organize work, recognizes and establishes appropriate work priorities, and completes work in a productive manner, without creating backlogs. Maintains proficiency in data entry skills. Assists physicians and their office staff to expedite scheduling, pre‑admission, Medicaid screening and pre‑certifications on all accounts. Resolves errors and applicable Claim, DNB and Patient Work Queues. Performs other duties as assigned. Budget/Financial Attempts to collect the estimated self‑pay balance of all inpatient, outpatient and ER accounts, at the earliest possible collection control point. Monitors in‑house accounts and attempts to make financial arrangements with guarantors for payment of their self‑pay balances in full and prior to discharge. Completes financial evaluation forms to document guarantors' income, expenses, assets and liabilities. Identifies those patients without adequate insurance coverage. Makes personal contact with patient or guarantor to determine guarantor's ability to pay non‑covered charges, as well as to determine potential eligibility for financial assistance programs (namely Medicaid). Maintains a list of health care financial assistance programs and the eligibility requirements for each program. Refers patients/guarantors to sources of outside funding assistance, as needed. Works efficiently and accurately within designated time frames to ensure a continuity of information and cash flow. Contacts scheduled patients at home to obtain pre‑admission information, explain financial policies, estimate self‑pay balances, and obtain a promise to pay on or before admission/registration. Interviews all inpatients and select (self‑pay) outpatients at time of registration, or at least within 24 hours of admission, to verify complete insurance and financial information, explain financial policies, and collect the estimated self‑pay balance. Documents concise and understandable notes regarding all self‑pay account collection activity, as well as each patient or guarantor interaction. Documents all efforts to collect patient account balances, other self‑pay collection activities and referrals to Medicaid. Coordinates financial counseling activities with Admitting, Outpatient Registration, Emergency Registration, Utilization Review, Nursing, Social Services, and Patient Financial Services. Verifies insurance coverage and benefits. Exceeds monthly quota on a consistent basis. Formally reports results of self‑pay collection activity to direct supervisor, on a daily basis or according to policy. Provides feedback to PAS management concerning self‑pay collection and data integrity issues. Responsible for completion of appropriate error/issues in WorkQueues. Identifies and resolves Payor Denials as indicated. Customer Service Greets all guest with a positive and professional attitude. Receives patients valuables for safekeeping in the hospital safe. Answers incoming phone calls and follows through with requests made. Maintains courteous and cooperative working relationships with WHS management, patients, physicians, other professional contacts, and the general public. Demonstrates ability to tactfully handle difficult situations. Presents a well‑groomed and professional image in coordination with dept/ hospital dress codes. Expected Performance, Behaviors and Results: The WellStar Experience (Must demonstrate a commitment to Service Excellence by): Creating first impressions, memorable moments and impressions that fulfill the expressed and unexpressed wishes and needs of patients and family members. Valuing patients and family members as partners in their care. Having world‑class processes in place. Delivering high‑touch care that is reliable, responsive and coordinated. Focusing on constant innovation and creating improvements. Celebrating our diversity with sensitivity and understanding. Embracing the idea that we are all owners of our health system. General Observes work hours and provides proper notice of absences, tardies work schedule changes. Attends select departmental meetings at the request of WHS Management. Completes monthly, quarterly, and annual mandatory training as required. Performs other duties as assigned. PAS III Team members serve as preceptors and mentors and as such must: Maintain a based on individual QA audit /or as reported by Epic (min. of 10 accounts) registration accuracy rate or higher in the past 12 months. Maintain minimum productivity requirements. Has no corrective disciplinary action during the past twelve (12) months. Willing and able to function as a preceptor in the orientation of new patient access personnel and students. Maintain required certifications by obtaining necessary CEUs and submitting timely to certifying board. Performs other duties as assigned. Complies with all WellStar Health System policies, standards of work, and code of conduct. Required Minimum Education High School Diploma General or Associates Other-Preferred Required Minimum License(s) And Certification(s) All certifications are required upon hire unless otherwise stated. CHAA - Cert Healthcare Access Assoc or CPAR - Certified Patient Account Rep or CRCR - Certified Revenue Cycle Rep or CRCR-P - Certified Revenue Cycle Rep - Provisional (90 Days) within 120 Days Required Minimum Experience Minimum 1 year of healthcare experience in Patient Access Services, Practice Operations, or Patient Financial Services. Required and Bachelors degree or higher may substitute for experience. Required and Epic experience Preferred Required Minimum Skills Effective communication skills (both written and verbal) with the ability to communicate with various members of the healthcare team. High attention to detail, self-directed and a positive attitude are essential. Effective problem solving and critical thinking skills. Typing or data entry competency of at least 40 words/minute. Cash handling and balancing. Demonstrated professionalism, effective communication skills and active listening skills. Working knowledge of patient registration systems and intermediate Microsoft Office Suite are preferred. Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more. #J-18808-Ljbffr