JOB TITLE: Insurance Authorization Manager
EMPLOYER: Twelfth One, LLC dba Aspen Infusion
DEPARTMENT: Authorization
REPORTS TO: Chief Operating Officer
SUMMARY: An insurance authorization manager oversees a team responsible for obtaining prior authorizations from insurance companies for medical services, ensuring timely approvals by coordinating with patients, healthcare providers, and insurance carriers while adhering to compliance regulations and optimizing revenue cycle management by monitoring authorization processes and addressing any potential issues with coverage or denials.
DUTIES AND RESPONSIBILITIES:
Leadership & Team Management:
- Lead and supervise a team of insurance authorization specialists.
- Assign tasks, monitor performance, and provide coaching to ensure accurate and efficient authorization processes.
- Conduct staff training on insurance guidelines, medical coding, and authorization procedures.
- Provide training and development opportunities to staff.
- Oversee staffing, scheduling, and task assignment to ensure proper coverage and efficient workflow in the production area.
- Conduct performance reviews, identify areas for improvement, and foster a culture of continuous improvement, accountability, and teamwork.
Authorization Process Oversight:
- Communicate effectively with patients, healthcare providers, billing staff, and insurance companies to gather necessary information and address any concerns regarding authorizations.
- Review patient medical records and insurance benefits to determine required authorizations for upcoming procedures or treatments.
- Initiate and follow up on prior authorization requests with insurance companies via phone, fax, or electronic systems.
- Monitor pending authorization requests and escalate any potential delays or denials to appropriate parties.
- Develop, review, and suggest changes to customer service policies and procedures as needed.
- Generate reports on authorization metrics such as approval rates, denial rates, and turnaround times to identify trends and areas for improvement.
- Analyze data to identify potential issues with insurance coverage or billing practices and propose solutions.
- Perform other related duties as assigned by management.
Collaboration with Human Resources & Recruitment Teams:
- Recruit, hire, and direct customer service department staff members.
- Arrange for performance evaluation of each member of the customer service department staff annually; establish annual performance goals, and monitor progress toward these goals on a consistent basis.
- Review and approve time clocks for department staff.
- Delegate authority as necessary to ensure that all responsibilities of this position are fulfilled in a timely and accurate manner.
Collaboration with Billing & Nursing Teams:
- Coordinate with the Revenue Cycle Management team regarding appropriate authorization and accurate claim submission.
- Coordinate with Nursing Teams to maintain a consistent service delivery message amongst all departments (i.e. initial interaction to the follow-up).
- Collaborate with clinical staff to understand treatment plans and identify potential authorization challenges.
Quality Control & Regulatory Compliance:
- Ensure adherence to all state and federal regulations regarding patient privacy and insurance billing practices.
- Regularly audit authorization processes to identify areas for improvement and maintain compliance with payer guidelines.
- Address any authorization issues or discrepancies with insurance companies to resolve billing disputes.
- Report any misconduct, suspicious, or unethical activities to the Compliance Officer.
- Participate in surveys conducted by authorized inspection agencies.
- Participate in the pharmacy’s Performance Improvement program as requested by the Performance Improvement Coordinator.
- Participate in pharmacy committees when requested.
- Ensure ongoing compliance with all laws and regulations; ensure that the department meets or exceeds accreditation standards, and implement 'best practices' in all departmental activities.
Ongoing Education Responsibilities:
- Participate in in-service education programs provided by the pharmacy.
- Pursue continuing education programs appropriate to job responsibilities.
QUALIFICATIONS:
- 2-year college degree is preferred but not required.
- 3-5 years related supervisory experience and/or training, or equivalent combination of education and experience.
- Strong communication skills.
- Technically proficient in platforms such as Google Suite (Docs, Forms, Sheets), Gmail (email, calendar), Paylocity (Employee/HR Platform), RingCentral/Glip, and Caretend (EMR system) experience is a plus.
- Ability to organize and plan the activities of subordinates, and to delegate appropriately.
- Organizational skills sufficient to maintain consistently accurate records.
- Experience in Customer Service and leadership roles.
- Ability to evaluate options and to make efficient decisions.
COMPETENCIES:
- Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.
- Delegation - Delegates work assignments; Matches the responsibility to the person; Gives authority to work independently; Sets expectations and monitors delegated activities; Provides recognition for results.
- Managing People - Includes staff in planning, decision-making, facilitating and process improvement; Takes responsibility for subordinates' activities; Makes self-available to staff; Provides regular performance feedback; Develops subordinates' skills and encourages growth; Solicits and applies customer feedback (internal and external); Fosters quality focus in others; Improves processes, products, and services; Continually works to improve supervisory skills.
- Problem-Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem-solving situations; Uses reason even when dealing with emotional topics.
- Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed.
PHYSICAL DEMANDS AND WORK ENVIRONMENT:
- Continually required to stand, walk, sit, talk, and hear.
- Continually required to utilize hand and finger dexterity.
- While performing the duties of this job, the noise level in the work environment is moderate.
- The employee must occasionally lift and/or move up to 30 pounds.
- Specific vision abilities required by this job include: Close vision; Distance vision; Peripheral vision; Depth perception and ability to adjust focus.
The above is intended to describe the general content of and requirements for the performance of this job. It is not to be construed as an exhaustive statement of duties, responsibilities, or physical requirements. Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
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