Radiology Authorization & Eligibility Specialist

Under direct supervision, performs all eligibility, verification and authorization requests required for all Radiology patients. Responsible to obtain ongoing authorizations to secure reimbursement of services. Acts as liaison with insurance companies' utilization review departments to ensure all insurance company policies are met. Works collaboratively with the billing team to ensure coverage for dates of service for all patients. Ensures re-verification of all Radiology patients.
Continuously reviews and remains compliant with ever-changing information from insurance companies. Provides ongoing reporting to management regarding status and challenges encountered.

Education:

High School

Experience:

2 years of progressive insurance authorization experience preferred. Epic experience desired.

Skills:

• Thorough knowledge of authorization processes
• Basic understanding of insurance policies/procedures
• Detail oriented with excellent telephone, analytical, organization and time management skills
• Collaboration with clinical staff regarding challenging patient needs
• Basic understanding of complete revenue cycle
• Knowledge of ICD-10 and CPT coding practices
• Strong computer skills, including EMR knowledge and Microsoft Office
• Skill in data analysis and interpretation
• Strong interpersonal skills
• Ability to work in a fast-paced environment and meet frequent deadlines
• Ability and initiative to plan for and complete daily activities with minimal direction
• Ability to assist with process and procedure development

Principal Duties and Responsibilities:

• Verifies patient's insurance eligibility, benefits, and authorization requirements for specific imaging procedures.

• Collaborates with members of all care teams to ensure effective communication regarding all commercial insurance issues.
• Facilitates problem-solving with clinical departments, providers, referral sources, insurance companies, and authorization staff.
• Accurately obtains insurance authorization for patients
• Ensures authorization is provided in a timely manner.
• Comprehensively documents insurance discussions in the Epic referral to communicate up to date details with colleagues.
• Collaborates with Oncology staff, Pharmacy Team, RN Navigators, and Laboratory services to minimize denials and obtain authorizations in a timely manner. Prioritizes authorization requests according to medical urgency.
• Reviews medical records for submission to insurances, abstracting information from patient medical records pertaining to patienttreatments, procedures, and guidelines as required.
• Reviews patient treatment plan including frequency and dosage prior to treatment and reviews the applicable payer reimbursement
• criteria to ensure that the specific payer's medical necessity criteria are met.
• Track authorization status and follows up on pending or denied requests. Maintains a 4-day window to ensureunauthorized procedures are removed from the schedule.
• Communicates any changes in schedule to patient as well as authorization status and any out-of-pocket expenses to the patient in a timely manner.
• Quickly and courteously responds to concerns from patients, staff, and others involved in patient care while maintaining a respectful demeanor.
• Conducts outbound calls to patients and providers for patient support. Accepts inbound calls from patients and providers to provide support.
• Follows departmental standards to document all calls.
• Promptly identifies and resolves all operational issues affecting insurance verification and authorization to ensure a smooth workflow from order creation to billing.
• Works closely with nursing staff to ensure that patients are scheduled in a timely manner.
• Maintains internal processes to comprehensively track authorization requirements by patient and follows up as appropriate utilizing established Epic work queues.
• Assists with appeals and denial management as necessary
• Maintains current knowledge of payers' requirements for pre-authorizations, certifications and verifications.
• Assists with training new hires in authorizations
• May perform other duties as assigned.

All roles must demonstrate GBMC Values

Respect

I will treat everyone with courtesy. I will foster a healing environment.

• Treats others with fairness, kindness, and respect for personal dignity and privacy

• Listens and responds appropriately to others' needs, feelings, and capabilities

Excellence

I will strive for superior performance in every aspect of my work. I will recognize and celebrate the accomplishments of others.

• Meets and/or exceeds customer expectations
• Actively pursues learning and self-development
• Pays attention to detail; follows through

Accountability

I will be professional in the way I act, look and speak. I will take ownership to solve problems.

• Sets a positive, professional example for others
• Takes ownership of problems and does what is needed to solve them
• Appropriately plans and utilizes required resources for various job duties
• Reports to work regularly and on time

Teamwork

I will be engaged and collaborative. I will keep people informed.

• Works cooperatively and collaboratively with others for the success of the team
• Addresses and resolves conflict in a positive way
• Seeks out the ideas of others to reach the best solutions
• Acknowledges and celebrates the contribution of others

Ethical Behavior

I will always act with honesty and integrity. I will protect the patient.

• Demonstrates honesty, integrity and good judgment
• Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers

Results

I will set goals and measure outcomes that support organizational goals. I will give and accept help to achieve goals.

• Embraces change and improvement in the work environment
• Continuously seeks to improve the quality of products/services
• Displays flexibility in dealing with new situations or obstacles
• Achieves results on time by focusing on priorities and manages time efficiently

Pay Range

$19.92 - $29.87

Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.

Equal Employment Opportunity

GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.