Referral and Authorization Specialist - Practice Support
$36,421–$47,133 year
On-siteFrederick, Maryland, United States
Job Summary
Complete pre-determination and authorization processes for in-house procedures, verifying patient demographics, financial information, and insurance eligibility prior to service delivery. Obtain primary care physician approval for referrals, calculate price estimations per payer fee schedule, and complete referrals to participating providers within the appropriate network. Answer phone inquiries regarding referrals, pre-authorizations, and medical necessity while collaborating with clinical contacts on escalations requiring peer-to-peer review. Submit clean claims, reduce payer denials, and offer patient portal enrollment to non-enrolled individuals. Maintain updated knowledge of insurance guidelines, provider networks, and organizational quality metrics to support departmental productivity goals.
Required Qualifications
- High school diploma or GED
- Some college coursework related to Business/Health Sciences
- A minimum of two years healthcare experience in revenue cycle billing and collections
- A minimum of one year experience in obtaining authorization and pretermination
- Understanding of medical terminology, CPT and ICD-10 codes
- Extensive knowledge of health insurance plans including, Medicare, Medicaid, HMO's and PPO's
- Attention to detail, with the ability to analyze and determine the type of data needed to complete various types of patient registration functions
- Ability to manage time, deadlines, multiple request and priorities, maintain productivity and exercise good judgement with minimal supervision
- Clinical knowledge, to include medical terminology, medications, procedures/radiology, procedures and surgeries from all different medically specialty services
- Ability to apply policies and procedures regarding data security and patient confidentiality (HIPAA) to prevent inappropriate release of patient information
- Proficiency in the use of computer software such as Microsoft Word, Microsoft Outlook, Microsoft Excel, NextGen, Meditech, Meditech Expanse, and the usage of the intranet
- Ability to operate a copier, fax machine, and printer
- Excellent verbal and written communication skills to interact effectively with patients, customers, employees and Senior Leaders
- Ability to follow verbal and written instructions
- Ability to work in a changing environment, accept and give constructive criticism and feedback
- Ability to work well with others in a team-oriented environment
- Strong customer service background to include a pleasant disposition and high tolerance level
- Must be able to lift 15 pounds on an infrequent basis (less than one lift every three minutes)
Desired Qualifications
- Strong customer service background to include a pleasant disposition and high tolerance level
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