Authorization Specialist Job Description
Authorization specialist
provides support for Clinical Programs to create and maintain prior authorization guidelines for clinical product offerings.
Authorization Specialist Duties & Responsibilities
To write an effective authorization specialist job description, begin by listing detailed duties, responsibilities and expectations. We have included authorization specialist job description templates that you can modify and use.
Sample responsibilities for this position include:
Handle Authorization submissions and follow ups for all Insurance Payors including Medicare, Medicaid’s, HMO and PPO’s
Answers incoming calls received through the toll free Pre-Authorization Support ACD and provide appropriate call/case handling
Performs initial benefit verification and pre-surgical authorization for new pre-surgical cases by working closely with all payers
Documents case status, actions, and outcome in the Pre-Authorization Support contact management database utilizing who, what, where, when, how
Communicates and builds relationships with HCP offices and sales representatives in regards to all inquiries for the handling of cases, , missing case information, benefits
Responsible for notifying the appropriate internal departments based on receipt of information that department needs to be aware of including complaint handling/ adverse event notifications
Utilizes customer service skills in engaging with customers, communications with Sales representatives, and working in teams in a call center environment to expedite processing of cases
Updates patient insurance and demographics information as needed
Easily manages multiple authorization requests at once
Follows-up on post-claim denials
Authorization Specialist Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Authorization Specialist
List any licenses or certifications required by the position: CPC, HFMA, NAHAM, CHAA, CPAR, PHAT, PHATP, CISSP, CHONC, HCPCS
Education for Authorization Specialist
Typically a job would require a certain level of education.
Employers hiring for the authorization specialist job most commonly would prefer for their future employee to have a relevant degree such as Associate and High School Degree in Medical, Associates, Healthcare, Education, Business/Administration, Health Care Business, Business, Nursing, Communication, Supervision
Skills for Authorization Specialist
Desired skills for authorization specialist include:
Medical terminology
Clinical policies
Insurance carrier guidelines
State guidelines pertaining to referrals and prior authorization
Equivalent combination of education and experience
GED
Office procedures normally acquired through completion of a High School diploma
ICD-10 and CPT codes
Medicare
State and federal regulatory guidelines for coverage and authorization
Desired experience for authorization specialist includes:
College undergraduate degree strongly preferred
Submit clinical documentation for authorization of various high cost pharmaceuticals, radiopharmaceuticals, and off-label chemotherapy regimens
Collaborate as part of an inter-disciplinary team related to the previously mentioned processes
Serve as a clinical resource to the Revenue Integrity & Billing Compliance team
Collaborate with the Prior Authorization Manager to review and appeal rejected claims in a timely fashion
Assist in the Revenue Integrity Specialist with prior authorization denials
Authorization Specialist Examples
1
Authorization Specialist Job Description
Job Description Example
Our company is searching for experienced candidates for the position of authorization specialist. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for authorization specialist
- Ensure that all assigned Authorizations are resolved within appropriate time restraints
- Research, follow-up, and resolve all open/pending Authorizations in a timely manner
- Contact Payors for status of outstanding/pending Authorization request
- Minimum requirements of 35-45 Authorization submissions and or follow ups daily
- Verifies patient insurance eligibility and benefits by means of Internet resources or manually procuring information from the insurance carrier
- Conveys information regarding procedure codes and diagnostic codes in order to receive correct referrals for office visits and authorization for inpatient and outpatient hospital procedures
- Communicates and coordinates with interdepartmental and interoffice personnel to procure correct and detailed information regarding all referrals and authorizations
- Updates and informs all parties involved of any insurance or procedural changes regarding authorizations or office visit referrals
- Obtains all referrals and authorizations for office visits and procedure and hospital in patient/out patient procedures same day
- Identify primary and, as applicable, additional payers, based on established payer coverage guidelines and criteria
Qualifications for authorization specialist
- Must be able to work in a fast pace environment in which information is constantly changing
- Licensed as a Registered Nurse in the Commonwealth of Massachusetts preferred
- Case Management, Utilization Review or Prior Authorization experience is preferred
- Minimum of 3 years clinical and/or related experience
- Knowledge of third party payer rules and regulations preferred
- Well organized and able to multi-task quickly and effectively
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Authorization Specialist Job Description
Job Description Example
Our company is growing rapidly and is searching for experienced candidates for the position of authorization specialist. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for authorization specialist
- Ensure open communication thru communicating with administrative and field associates regarding the status of authorization requests, authorizations and related reimbursement issues
- Research address/benefit changes per FSU/insurance Company’s request and makes corrections as necessary to ensure payment by the insurance carrier
- Review reports and/or pre-billing edits on a regular basis for all assigned branches and notify managers when issues are present that delay billing and/or cause payment to be denied
- Review and monitor the drug authorization workqueue, identifying patient treatment/therapy plans that require prior authorization
- Prepare and complete payer-specific prior authorization request forms, interpret medical policy criteria, and apply appropriate guidelines to prior authorization requests
- Review and comprehend patient progress notes, lab reports, infusion summaries, imaging reports, and plan of care
- Determine when documentation does not meet medical policy guidelines and coordinate appropriate follow-up by clinical staff members that aid in the prior authorization process
- Follow-up with appropriate parties to meet all deadlines and prevent prior authorization denials
- Manage prior authorization process from initial submission to authorization for all assigned cases
- Manage prior authorization reports to ensure appropriate drug dispenses are appropriately authorized and followed-up on
Qualifications for authorization specialist
- Must demonstrate ability to effectively build relationships and communicate with both internal and external customers
- Must be able to accurately document and verbalize issues and have the ability to work with in a team environment and across departments
- Must be able to work in an environment where meeting and executing on timelines is essential
- Works well in high-pressure situations
- Ability to work closely and effectively with peers across the organization and with the medical staff
- Motivated, shows initiative, and collaborates well in a team setting
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Authorization Specialist Job Description
Job Description Example
Our growing company is searching for experienced candidates for the position of authorization specialist. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for authorization specialist
- Independently monitors incoming drug prior authorization correspondences
- Orients and assists the training of new staff
- Schedule patient’s deliveries and address all patient needs in one phone call with a positive and caring attitude
- Ensures proper follow-ups are initiated so patient’s therapy is not disrupted.• Ensures individualized care goals are met
- Act as a central resource for the entire specialty across all sites to ensure authorization requirements by insurer are documented and available to procuring staff and that changes to requirements are communicated
- Act as subject matter expert in insurance authorization requirements and timeframes including but not limited to surgical and outpatient procedures
- Act as a central resource to collaborate/communicate with staff procuring authorizations and insurers as needed
- Acts as a central resource to proactively and continuously educated on regulations/ updates and supports a current knowledge base of source materials available to impacted staff
- Act as a central resource to manage, monitor, and validate pre-procedurally using a risk stratification method, that authorizations are available and correct for cases identified as high risk and/or high cost
Qualifications for authorization specialist
- Self-motivated, enthusiastic and detail oriented individual with great organizational skills that can work well with deadlines
- Knowledge of CPT Codes, ICD9 Codes and ICD-10
- Basic understanding of the benefits investigation process which includes deductible, out of pocket and benefit exclusions
- Minimum of two (2) years experience in the medical field
- Working knowledge of office referrals and surgical and hospital authorization procedures
- Master in Information Services (IT)
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Authorization Specialist Job Description
Job Description Example
Our company is looking for an authorization specialist. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for authorization specialist
- Act as a central resource to proactively identify admission type orders post procedurally that do not align with authorization and triage/escalate those admissions at risk of non-payment to case managers
- Act as a central resource to manage, monitor and track data related to underpayments, denials and revenue opportunities to plan/implement performance improvement strategies intended to reduce the number of denials
- Prepares a variety of reports from categorize denials based on root cause findings and trends and distributes reports to appropriate management, physician and staff to ensure continuous improvement
- Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and supports department-based goals which contribute to the success of the organization
- Researches and documents coverage determination requests for prior authorization (PA) by independently researching the EMR chart notes and historical clinical data to identify prior therapies and treatments
- Identifies insurance treatment requirements and reviews the medical record to assure the insurance requirements are met for prior authorization approval
- Responsible for applying clinical knowledge when assessing and responding with alternatives to deniedauthorizations for Pharmacy and Medical Service
- Reviews clinical documentation in the Electronic Medical Record and preps findings and research for providers (may be responsible for over 50 provider panels) when further clinical clarification is needed in the prior-authorization process to meet insurer contractual requirements and optimize patient outcomes
- Packages and provides alternate options to the provider when an authorization is denied
Qualifications for authorization specialist
- Strong technical skills on SAP authorization management (relevant Sap tables as AGR_*, TOBJ, PFCG… )
- Strong technical knowledge on identity management life cycle processes
- Knowledge of data security, segregation of duties and risks management principles and how it impacts the operations
- A minimum of 5 years of experience within the area of authorization management in SAP solution is required
- Strong set of broad technical skills and expertise with word processing, spreadsheet, and database software to analyze, organize, and present information
- Excellent organizational skills, including a strong orientation to detail and deadlines
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Authorization Specialist Job Description
Job Description Example
Our company is looking to fill the role of authorization specialist. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for authorization specialist
- Works closely with and supports team efforts to accomplish authorization
- Provides effective communication to team members and other health care professionals and maintains confidentiality
- Ensures insurance patient’s coverage, resolves any issues with authorization and escalates complicated issues to the appropriate manager
- Works to establish timely, correct insurance prior to the patient’s procedure in order to financially secure the prior authorization, promotes good customer service, efficient and accurate billing and prompt reimbursement
- Demonstrates ability to adjust service approaches to reflect developmental level of population served
- Maintains compliance with departmental quality standards and productivity measures
- Utilize authorization resources along with any other applicable reference material to obtain accurate prior authorization
- Reviews and interprets medical record documentation for patient history, diagnosis, and previous treatment plans to pre-authorize insurance plan determined procedures to avoid financial penalties to patient, provider and facility
- Utilizes payor-specific approved criteria or state laws and regulations to determine medical necessity or the clinical appropriateness for inpatient admissions, outpatient facility, office services, durable medical equipment, and drugs in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury, or disease
Qualifications for authorization specialist
- Must possess strong computer skills and have working knowledge of Microsoft outlook, Microsoft Word and Excel
- Must have exceptional organizational skills and a keen attention to detail, and be multi-task oriented
- Familiar with standard concepts, practices and procedures within the Patient Access field
- Previous work experience within a higher education environment
- At least one year of compliance work experience or demonstrable comparable skills
- At least one year of database work experience or demonstrable comparable skills