Specialist - Authorization (Tawam Fertility Center)

Role Overview

Specialist - Authorization at Tawam Fertility Center, SEHA. This role manages pre-authorization requests and insurance verification to support patient care delivery and revenue cycle operations.

Role Purpose

Initiate and manage pre-authorization requests to payers for claims requiring approval. Monitor medical necessity and appropriateness of services, communicate with payers, patients, physician offices, and hospital clinical staff, and ensure accurate documentation of all authorizations and pre-certifications.

Key Responsibilities

Authorization & Pre-Certification

• Serve as primary contact for all SEHA Business Entity prior authorization requirements.
• Initiate pre-authorization requests to payers for claims that require approval.
• Pre-certify procedures ordered by physicians.
• Confirm pre-certifications that have been obtained or obtain pre-certifications if needed.
• Contact payers to obtain prior authorization and gather additional clinical and coding information as necessary.
• Monitor appropriateness and medical necessity of requested services.

Payer & Insurance Communication

• Contact insurance companies by phone, fax, or online portal to obtain insurance benefits, eligibility, and authorization information.
• Work with inpatient accounts for authorization and provide timely notification to payers of patient admission to protect financial standing.
• May contact physicians, Case Management, and Utilization Review to facilitate the sending of clinical information in support of authorization to the payer, as assigned.
• Contact payers to obtain prior authorization information.
• Understand payer processes including website, fax, and contact number to submit appropriate clinical documentation.

Documentation & Systems Management

• Update systems with accurate information obtained from payers.
• Ensure all benefits, authorizations, pre-certifications, and financial obligations of patients are documented on account memos, clearly, accurately, precisely, and in detail to ensure expeditious processing of patient accounts.
• Provide standardized documentation within the system to identify prior authorization and the criteria surrounding such authorization.
• Use utmost caution that obtained benefits, authorizations, and pre-certifications are accurate according to the actual test, procedure, or registration being performed.

Team & Clinical Coordination

• Serve as the primary resource for SEHA Business Entity regarding prior authorization process and requirements.
• Serve as the primary resource to patients regarding the prior authorization process.
• Communicate to service line partners of situations where rescheduling is necessary due to lack of authorization or limited benefits, as approved by clinical personnel.
• Monitor team mailbox, email inbox, faxes, and phone calls, responding to all related Pre-Access account issues within defined time frames.

Information & Research

• Collect clinical information regarding services to be rendered.
• Stay informed and research information regarding insurance criteria for prior authorization.

Qualifications & Experience

• 12 years of Revenue Cycle Experience in lieu of degree.
• Healthcare Certification: CRCR and/or CHAM.
• Minimum two (0-2) years of medical insurance verification and authorization required.
• Minimum of (0-2) years documented and recent experience in a medical facility setting where the use of electronic systems for complex coding, insurance issues, pre-certification, and outbound referral management is evident.
• 1-3 years of prior authorization experience in a large healthcare, multi-integrated network, or third-party medical billing environment.
• Experience, testing, or academic coursework completion of CPT, ICD-10, HCPCS, LMRPs, and similar coding and guidelines.
• Experience with third-party payer requirements, contracts, authorization, and payment practices.
• Billing and coding experience preferred.

Skills & Competencies

• Extensive knowledge of healthcare revenue cycle systems.
• Understanding of insurance requirements for prior authorization.
• Knowledge of registration, verification, pre-certification, and scheduling procedures.
• Understanding of payer processes to submit appropriate clinical documentation.
• Proficient knowledge of Microsoft Office and Outlook.
• Proficient knowledge of Medical Terminology and Medical Coding.
• Understanding of insurance billing procedures and practices.
• Knowledge of ICD-10 and CPT-4.
• Experience with insurance terminology required.