Job Opportunity Job ID: 27187 Positions Location: Lansing, MI Job Description General Purpose of Job: This Description:
Positions Location: Lansing, MI
General Purpose of Job:
This role is responsible for validating the financial authorization for surgical services for the faclity. The Authorization Specialist works closely with insurance companies, physician office personel and clinical staff to secure payment for services. The accuracy of these tasks will ensure authorization and medical necessity for high revenue services and secure payment for the health system.
This job description is intended to cover the minimum essential duties assigned on a regular basis. Associates may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.
- Validate coverage information and update in Epic system when necessary
- Determine if authorization is required per payer specific guidelines
- Send Notification to Payer per payer specific guidelines via phone, website, fax
- Assess patient treatment and therapy plans to determine authorization requirements.
- Develops relationships with clinical staff and physicians to secure payment for services related to patients therapy and treatment plans.
- Responsible for providing all required medical information to insurance companies as necessary to facilitate the authorization process.
- Works with specialty pharmacies to obtain authorization for prescription medications.
- Assist in educating and acts as a resource to clinicians and support staff regarding authorizations and medical neccessity.
- Follow up on insurance determination within specified time frames.
- Coordinates resolution of escalated member or provider inquiries as related to prior authorization or denial of authorization.
- Communicates to clinicians or other medical staff regarding prior authorizations and pre-certifications especially if a medical procedure or medication has been denied authorization.
- Checks for medical necessity and ICD-10CM code per payer specific guidelines
- Verify insurance eligibility and covered benefits by using all electronic systems available or by phone.
- Determine if planned procedures and treatments are in the inpatient only list and ensure prior authorization is established accordingly.
- Ensure the patient class for the stay coordinates with the payer approval and follow up as necessary
- Provide CPT codes when missing or for add-on procedures
- Identify the diagonosis and ICD-CM code associated to payer for medical necessity of test (MRI, Surgical Procedure, CT, etc.)
- Work exception accounts held internally or rejected by payers for errors related to authorization.
Sparrow Health System is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veteran status.Job Family Administrative/Clerical Requirements: Shift Days Degree Type / Education Level Associate Status Full-time Facility Sparrow Hospital Experience Level Under 4 Years
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