Job ID 2028
Career Level Coder
Experience 2 Years
Qualifications Bachelor's Degree
- Verifies insurance eligibility and benefit levels to ensure adequate coverage for identified services prior to receipt, pt estimation calculation
- Successfully works with payers via electronic / telephonic and / or fax communications.
- Responsible for verification and investigation of pre-certification, authorization, and referral requirements for services
- Coordinates and supplies information to the review organization (payer) including medical information and / or letter of medical necessity for determination of benefits.
- Collaborates with designated clinical contacts regarding encounters that require escalation to peer-to-peer review.
- Communicates with clinical partners, financial counsellors (Pt estimation), and others as necessary to facilitate authorization process.
- Facilitates submission of clean claims and reduction in payer denials by adhering to both organizational and departmental policies and procedures and maintaining departmental productivity and quality goals.
- Appropriately prioritizes workload to ensure the most urgent cases are handled in a timely manner. Completes accurate documentation in both the Auth / Cert and Referral Shells.
- Completes notification to all payers via electronic / fax / telephonic means within 24 business hours of service to ensure compliance with Managed Care contractual requirements.
- Ensures timely and accurate insurance authorizations are in place prior to services being rendered.
- Follows departmental policies and procedures when necessary authorization is not obtained prior to service date.
- Answers provider, staff(prognosis messages), and patient (email from CM, PFS) questions surrounding insurance authorization requirements.
- Demonstrate and apply knowledge of medical terminology, high proficiency of general medical office procedures including HIPAA regulations.
- Communicate any insurance changes or trends among team.
- Clearly document all communications and contacts with providers and personnel in standardized documentation requirements, including proper format.
- Denial management, finding trends / Medical policies beneficial for pre-auth process / Identify and report trends and prior authorization issues relating to billing and reimbursement.
- Performs other related duties as required or assigned.