Job Description The Authorization & Cost Estimate Specialists are responsible for collecting necessary insurance benefit and clinical information to authorize services or provide an accurate cost estimate for services based on the patient's insurance benefits. This is a remote position that does require onsite attendance quarterly or as needed for training purposes.
The Authorization Specialist must have clinical knowledge of services so appropriate information can be communicated/given to the insurance company which will ensure the service is rendered in the correct level of care. Reimbursement for the service rendered is dependent upon the insurance benefit verification process and meeting the authorization requirements of the insurance company.
The Cost Estimate Specialist determines the cost for the service by applying the patient benefits / coverage information and estimate functionality accessible through IT applications. This process is essential to ensuring the patient understands their financial responsibilities for the service rendered. This is a very dynamic environment as insurance plans, benefits, and coverage structures change frequently and the turnaround is essential so that treatment is not delayed.
This individual will need expert knowledge of insurance plans, insurance regulations, and insurance benefit and coverages as they relate to the service rendered. Additionally, this team serves as a point of contact within the organizations for questions and issues as they relate to insurance plans and coverage information.
The duties and responsibilities this individual performs is solely dependent on the organization receiving reimbursement for the service rendered and ensuring the patients cost are clearly identified.
Responsibilities Authorization - Utilizes online systems, phone communication, and other resources to verify eligibility and benefits, determine extent of coverage, secure pre-authorizations, and determine patient liabilities within a timeframe before scheduled appointments determined by The Christ Hospital Health Network and during or after care for unscheduled patients.
- Verifies medical necessity in accordance with the Centers for Medicare & Medicaid Services (CMS) standards and communicates relevant coverage/eligibility information to the patient.
- Coordinates benefits by effectively determining primary, secondary, and tertiary liability when needed.
- Obtains pre-certifications and pre-authorizations from third-party payers in accordance with payer requirements.
- Alerts physician offices to issues with verifying insurance and/or obtaining pre-authorizations.
- Demonstrates understanding of insurance terminology (e.g., co-payments, deductibles, allowances, etc.), and analyzes information received to determine patients' out-of-pocket liabilities.
- Connects patients with financial counselors when further explanation or education is needed or requested regarding payment plans or financial assistance; may conduct some basic financial counseling duties as necessary.
Cost Estimates - Utilizes online systems, phone communication and other resources to verify eligibility and create a cost estimate for scheduled services based on patient benefits.
- Communicates liabilities directly to patients and provides education on key insurance terms and rules; may often handle patients with more complicated insurance plans (e.g., workers' comp)
- Documents the cost estimate in the EHR so that it can be collected prior to or on the date of service by Patient Access Coordinators and front desk staff.
- Demonstrates understanding of insurance terminology (e.g., co-payments, deductibles, allowances, etc.), and analyzes information received to determine patients' out-of-pocket liabilities.
- Connects patients with financial counselors when further explanation or education is needed or requested regarding payment plans or financial assistance; may conduct some basic financial counseling duties as necessary.
- Notifies physician offices when patients are scheduled that have out of network or limited benefit plans.
Communication - Communicates with patients, physicians, clinicians, front-end staff, or translators to obtain missing patient demographic or insurance information.
- Communicates liabilities directly to patients and provides education on key insurance terms and rules; may often handle patients with more complicated insurance plans (e.g., workers' compensation)
- Maintains excellent relationships with physician's offices, insurance companies and other hospital departments.
Qualifications KNOWLEDGE AND SKILLS: - Knowledge of the following preferred: EHR Programs (e.g., Epic), medical terminology, insurance plans and benefits
- Proficient critical thinking, detail oriented, and problem-solving skills
- Excellent communication (written and verbal) and interpersonal skills
- Exceptional time management, conflict resolution, and multitasking skills
- Works well in a team environment and able to work independently
- Proficient in Microsoft Office products
- Exhibits professionalism, trustworthiness, honesty, and integrity
- Customer service and/or call center experience preferred.
EDUCATION: High School Diploma or GED required. Associate or bachelor's degree in healthcare administration or related preferred.
YEARS OF EXPERIENCE: One to two years of registration or insurance verification related experience preferred.
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