Authorization and Benefits Coordinator

Gastro Health; Fairfax (VA); On-site; USD 42,000 - 54,000; Full time

Job summary

Gastro Health is seeking an Authorization and Benefits Coordinator to process referral requests and verify member eligibility and benefits. You will input service requests, request medical records when needed, and communicate with providers and health plans to ensure timely authorization.

In this role you will collaborate with various departments, maintain logs, and adhere to HIPAA policies while handling sensitive PHI and ensuring accurate data entry and responsiveness to urgent requests.

Qualifications

• Knowledge of insurance carrier requirements.
• 1 year or more of insurance verification and authorization experience.

Responsibilities

• Input requests for services received into the system for authorization and tracking.
• Communicate with requesting providers to clarify authorization needs (CPT codes, ICD10, timeframes, demographics).
• Request submission of medical records according to policy for the requested service(s).
• Notify parties within required timeframes for routine and urgent requests.
• Research member history for duplications and authorization limits.
• Provide services authorizations to appropriate facilities and forward to relevant staff.
• Scan, attach, review, and record information from attachments into authorization fields.

Skills

Insurance verification

Authorization experience

Communication

Data entry

Job description

About Gastro Health:

Gastro Health is an extensive and diverse group of professionals dedicated to digestive and liver health. Now with more than 120 locations in seven states, our team of physicians, advanced practice providers, nutritionists, technicians, and support team are on a mission to provide outstanding medical care and an exceptional healthcare experience.

Position Summary:

The Authorization and Benefits Coordinator receives referral requests from providers and Health Plans representatives. Assist in processing medical services requests. Completes clerical duties related to the processing of Authorization Requests, Provider Referrals and verifies member’s eligibility and benefits with subsequent notification to designated staff of eligibility issues.

Essential Functions include but are not limited to the following:

• Input requests for services received into the system accurately for electronically generated authorization and tracking.
• Communicates with requesting provider for any identified need to clarify a request for authorization, such as CPT codes, ICD10, requested timeframes, and member demographics.
• Requests submission of appropriate medical records according to established criteria for requested service(s) in accordance with the corresponding Policy and Procedure.
• Notifies required parties within the appropriate timeframe for routine and urgent requests for services.
• Research member history for duplications and consideration of authorization limits.
• Provides services authorizations to appropriate facilities.
• Forwards Authorizations to appropriate department staff in terms of eligibility and other coverage, pricing, and benefits issues.
• Scans, attaches, reviews, and effectively works with electronic images as part of the authorization process. Including recording the required information from attachments into the authorization fields.
• Collaborates with Supervisor, Network, and Claims Department Staff to resolve complex authorization issues.
• Appropriately forward all referral requests to the next level of clinical review as applicable and after verifying for completeness and appropriateness.
• Coordinates approved outpatient surgical procedures in a specialist's office and/or outpatient surgical facilities with the health plan's authorization department when applicable.
• Coordinates approved services with Home Health Providers, Plan discharge Planners, and Plan Members as delegated or required by Plan.
• Provides effective departmental communication with both internal and external sources and communicates areas of concern to the supervisor.
• Answer incoming calls and schedule office appointments; Verifies fax numbers and system updates.
• Maintains appropriate logs, records, and reports as established by Utilization Department.
• Is a resource person for PCP to refer to network specialist(s).
• Adheres to company HIPAA policies and procedures. Identifying, maintaining, and protecting sensitive HIPAA information (PHI) and following procedures to ensure the security of such information.
• Other duties as assigned.

Job Specifications/Qualifications

• Knowledge of insurance carrier requirements
• 1 year or more of insurance verification and authorization experience

Required Skills And Abilities

• Computer Literate
• Customer Service
• Data Entry
• Effective Communicator
• Must be willing to cross-train

Why You'll Thrive at Gastro Health

We look for team members who embody our values of Compassion, Collaboration, Integrity, Accountability, Empowerment, Continuous Improvement, Positive Attitude, and Customer Focus. These values guide how we care for our patients, support one another, and deliver exceptional healthcare every day.

Physical Requirements And Working Conditions

• Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of the position.
• Primarily performed in an office environment with moderate noise levels.
• Frequent sitting, standing, walking, bending, reaching, computer use, and communication.
• Occasional lifting up to 10 lbs., pushing/pulling, and climbing stairs.
• Frequent interaction with staff, managers, patients, families/caregivers, providers, vendors, and other business partners.
• May require occasional weekends, holidays, or varying shifts based on business needs.

Communication Requirements

Ability to effectively read, write, speak, and understand English to safely perform the essential functions of the position.