Authorization Specialist

Summit Health Management; Berkeley Heights (NJ); On-site; USD 52,000 - 65,000; Full time

Job summary

VillageMD is seeking an Authorization Specialist to obtain authorizations for surgical procedures, diagnostic testing, medications, DME, and referrals as part of the Revenue Cycle Department. You will verify insurance eligibility, navigate carrier guidelines and state policies, communicate with patients and providers, and help reduce denials while upholding patient confidentiality.

The role requires a high school diploma, familiarity with Microsoft Office, and experience with Epic; we offer a

Qualifications

• High School Graduate/GED Required.
• 2-4 years of related experience preferred.
• Experience with Microsoft Office Suite Required.
• Experience Standard Office Technology in a Window based environment & Microsoft Office Suite Required.

Responsibilities

• Identifies all appointments and procedures for assigned departments that require authorization by monitoring schedules, system reports and dashboards.
• Verifies insurance eligibility and benefits, and updates the patient’s insurance information as necessary.
• Completes referrals and prior authorizations in a timely manner according to department guidelines and workflows.
• Communicates clearly and effectively with patients, physicians, office staff and manager to resolve issues that may result in a denied or delayed authorization request.
• Demonstrates the ability to use electronic tools and systems to organize and process daily work.
• Collaborates with Reimbursement Department teams to limit denials and ensure proper reimbursement.
• Maintains patient confidentiality.

Skills

Communication

Insurance knowledge

Team collaboration

Education

High School/GED

Vocational/Technical training

2-4 years experience

Tools

Epic

Microsoft Office

Job description

About Our Company

We’re a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care. Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients' homes and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD, and Starling Physicians.

When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all. We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care.

Please Note: We will only contact candidates regarding your applications from one of the following domains: @summithealth.com, @citymd.net, @villagemd.com, @villagemedical.com, @westmedgroup.com, @starlingphysicians.com, or @bmctotalcare.com.

Job Description

The Authorization Specialist is responsible for obtaining authorizations for surgical procedures, diagnostic testing, medications, DME, outgoing referrals, and other services as part of the daily operations of the Revenue Cycle Department. Authorization Specialists must have a keen understanding of medical insurance and the clinical policies that determine the authorization protocols for each health plan.

Essential Job functions:

• Identifies all appointments and procedures for assigned departments that require authorization by monitoring the schedules, system reports, and dashboards
• Identifies the referral and authorization requirements of the patients’ insurance plans by using various on-line resources according to department workflows
• Demonstrates knowledge of insurance carrier guidelines, clinical policies, and state guidelines pertaining to referrals and prior authorization
• Verifies insurance eligibility and benefits, and updates the patient’s insurance information as necessary
• Completes referrals and prior authorizations in a timely manner according to department guidelines and workflows
• Communicates clearly and effectively with patients, physicians, office staff and manager to resolve issues that may result in a denied or delayed authorization request
• Demonstrates complete system knowledge, ability to run reports, document and manage referrals and authorizations, move correspondence, resolve eligibility and authorization holds, and other system tasks within the user’s security access
• Demonstrates the ability to request, prepare, and recognize the documentation required to support the medical necessity for the service being authorized
• Provides the supervisor and manager with immediate feedback on issues affecting workflow, reimbursement, and customer service
• Ensures that appropriate and accurate information is entered in the patient account
• Responds timely and collaborates effectively with the Reimbursement Department teams to limit denials and ensure proper reimbursement
• Collaborates with team members to meet department deadlines and benchmarks
• Demonstrates the ability to use the electronic tools and systems available to organize and process the daily work
• Anticipates and performs necessary job duties
• Maintains patient confidentiality

General Job functions:

• Expert in selecting the correct insurance package in Epic.
• Updates authorizations and claims to reflect the new insurance package.
• Expert in sorting work queues and reports to identify and process the daily work (Manage Schedules - Inbound Referral Report - Outgoing Referrals)
• Moves correspondence from the dashboard to the patient’s account.
• Expert in generally accepted insurance benefit terms and processes.
• Expert in Communication (Case and authorization notation - Physician and Practice location staff – Peers - Supervisor/Manager – Payers)
• Expert in requesting and preparation of supporting documentation such as medical records, dictation, and orders.
• Expert in investigation of authorization denials and appeals (Insurance – Patient)

Education, Certification, Computer and Training Requirements:

• High School Graduate/GED Required.
• Vocational / Technical School / Diploma Program Preferred
• 2-4 years of related experience Preferred
• Experience with Standard Office Equipment (Phone, Fax, Copy Machine, Scanner, Email/Voice Mail) Preferred.
• Experience Standard Office Technology in a Window based environment & Microsoft Office Suite Required.

About Our Commitment Total Rewards at VillageMD

Our team members are essential to our mission to reshape healthcare through the power of connection. VillageMD highly values the critical role that health and wellness play in the lives of our team members and their families.

• Medical, Dental, Life, Disability, Vision, FSA coverages and a 401k savings plan.

Equal Opportunity Employer

Our Company provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to, and does not discriminate on the basis of, race, color, religion, creed, gender/sex, sexual orientation, gender identity and expression (including transgender status), national origin, ancestry, citizenship status, age, disability, genetic information, marital status, pregnancy, military status, veteran status, or any other characteristic protected by applicable federal, state, and local laws.

We’re a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care. Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients' homes and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD and Starling Physicians. When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all. We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care. The work we do is changing the lives of our patients, our communities, and each other. Join us as we deliver the care we want to see in the world. Together, we can create better outcomes for all.