Authorization / Scheduler Lead Specialist

Job Summary:

The Patient Access Authorization Scheduler Lead Specialist will be responsible for completing accurate pre-registration, registration, and scheduling of hospital patients. Other duties will consist of verifying and documenting all insurance coverage, obtaining pre-certifications, authorizations, answering any questions and explaining policies clearly, verifying pre-authorization for exams, advising patients of their scheduled procedure estimated patient responsibility and other miscellaneous duties.

General Requirements:

• Performs all job responsibilities in alignment with the mission and vision of the organization.
• Performs other duties as required and completes all job functions as per departmental policies and procedures.
• Maintains current knowledge in present areas of responsibility (i.e., self-education, attends ongoing educational programs).
• Attends staff meetings and completes mandatory in-services and requirements and competency evaluations on time.
• Wears protective clothing and equipment as appropriate.

General Skills:

• Ability to communicate in English, both verbally and in writing.
• Additional languages preferred.
• Strong written and verbal skills.
• Basic Computer Skills

Working Conditions:

• General environment: Works in a well-lighted, air-conditioned area, with moderate noise levels.
• May be exposed to high noise levels and bright lights.
• May be exposed to limited hazardous substances or body fluids, or infectious organisms.
• May be required to change from one task to another or different nature without loss of efficiency or composure.
• Periods of high stress and fluctuating workloads may occur.
• May be scheduled as needed including overtime.

Physical Requirments & Demands:

• Have near normal hearing: Hear alarms/telephone/normal speaking voice.
• Have near normal vision: Clarity of vision (both near and far), ability to distinguish colors.
• Have good manual dexterity.
• Have good eye-hand foot coordination.
• Ability to perform repetitive tasks/motion.
• Continuously within shift (67-100%): Standing, Walking.
• Frequently within shift (34-66%): Bending/Stooping, Pushing/Pulling, Lift/carry up to 20lbs, Lift/carry > 20 lbs. with assistance.
• Occasionally within shift (1-33%): Sitting, Climbing, Twist at waist, Lift/Carry > 50 lbs. with assistance, Reaching above shoulder.

Mission Statement:

QUALITY HEALTHCARE: In our continuing effort to enhance the quality of life for the communities we serve, the Hospital Authority of Miller County is committed to the delivery of superior, safe, cost-effective healthcare through the provisions of education prevention, diagnosis and treatment.

Job Specific Competencies:

• Schedule Therapy Procedures and other procedures, as necessary.
• Answer telephones in a professional manner; directs calls as appropriate.
• Contacts all designated personnel in the event of any scheduling changes such as cancellations, additions, or time changes.
• Pre-register 98% of all scheduled patients a minimum of three (3) business days in advance of their arrival.
• Obtain, validate, and accurately enter in the computer system, the patient’s demographic and insurance information while maintaining an acceptable accuracy rate (95% plus) as evidenced by routine quality review. Information may be obtained from the physician’s office or the patient via direct contact, telephone, or fax.
• Identify and escalate complex authorization issues to senior team members.
• Obtain signatures on all necessary forms and documents required by hospital and by law.
• Ensure MSP Questionnaire is completed for every Medicare registration.
• Work closely and cooperatively with the physician office staff, schedulers and other hospital departments to schedule and prepare the required information before the patient’s arrival.
• Utilize online programs to verify insurance eligibility and benefits, documenting findings on the patient account. Assist by contacting the insurance company for pre-authorizations and pre-certifications as required prior to patient receiving service.
• Collect co-payment, deductible or co-insurance previously identified by the Insurance Verification Specialist or as indicated on the insurance card or online eligibility system, when the patient arrives for service.
• Log cash collected, generate receipts, and always maintain balanced cash.
• Meet monthly cash collection goals as determined collaboratively by Department Director and Manager.
• Responsible for knowing the functions of the phone system to professionally manage incoming calls, appropriately transfer calls, and assist with any internal calls when asked to do so by the Department Director, Manager or Supervisor.
• Consistently demonstrate premier customer service and communication skills with all internal and external customers/contacts and ensure the patient and their family members have the best hospital encounter possible.
• Meet established quality and productivity standards for self and for the team.
• Anticipate and adapt to change (e.g., hospital policy changes, operational/procedures, insurance changes) in a positive manner.
• Foster and reinforce team-based results.
• Adhere to time and attendance standards as outlined in the Human Resource Policy manual. Provide proper notification of absence or tardiness within established departmental time limits.
• Ensure patient confidentiality adhering to HIPAA guidelines.
• Demonstrate the knowledge, skills, and abilities (competencies) to perform the duties outlined above annually in the form of a test or as evidenced by daily quality review and direct observation of the Team Lead and the Department Director.
• Track and monitor productivity as requested.
• Keep Department Director’s (including Radiology) apprised of any delays in the authorization process.
• Remain current on scheduling, registration, insurance verification, and other patient registration processes to cover in the absence of other team members.
• Perform other duties as assigned.
• Informs supervisor/manager of problematic situations and demonstrates ability to support recommendations/decisions.
• Ability to maintain operational knowledge of all insurance requirements necessary to achieve optimal reimbursement.

Professional Requirements:

• Follows Code of Conduct policy.
• Adheres to dress code; appearance is neat and clean.
• Completes annual educational requirements.
• Maintains regulatory requirements.
• Maintains patient confidentiality at all times.
• Reports to work on time and as scheduled; completes work within designated time.
• Wears identification when on duty; uses computerized time clock system correctly.
• Completes in-services and returns in a timely fashion.
• Attends annual review and/or skills fair and department in-services, as scheduled.
• Attempts to end conversations and other interactions in a positive manner; leaves others with a good impression of the Hospital Authority of Miller County and its employees.
• Complies with all organizational policies regarding ethical business practices.
• Communicates the mission statement of the organization.

Guest Relations Standards:

(All guest relation violations are subject to disciplinary action up to and including termination):

• Always treat others in a friendly, helpful manner.
• Refers co-workers to proper sources when unable to provide an answer.
• Interacts with others in a professional and friendly manner.
• Takes interest in others and always gives full cooperation to fellow workers.
• Always maintains an open line of communication with other departments.
• Thoroughly familiar with the hospital and the services it offers.

Other:

• Responsibility to Report: It is the responsibility of every employee of HAMC to comply with federal, state and local laws and regulations, as well as, HAMC Policies and Procedures. Every employee is help accountable to participate in, comply with and report concerns to his or her supervisor or the Compliance Officer if illegal or unethical behavior is suspected.
• As an employee of HAMC, you have been granted user access to applicable ePHI systems based on your position. This user or role-based access is intended to give you the minimum necessary access to perform your job function(s) only and should be used only as applicable.

Other Duities:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Education, Credentials & Experience Requirements:

• High School graduate or equivalent.
• Minimum of five (5) years of progressive experience in a healthcare setting, with a strong focus on medical pre-authorization and appeals and a minimum associate degree is required.
• PACS= Prior Authorization Certification Specialist is required or within 6 months of hire date
• Expert knowledge of medical terminology, ICD-10, and CPT coding.
• Generate reports and analyze authorization data to identify areas for improvement.
• Previous experience in appointment scheduling in a health care environment is required (e.g., physician office, clinic, or hospital).
• Extensive understanding of various insurance plans, including commercial, Medicare, and Medicaid.
• Collaborate closely with physicians, clinical staff, and case managers to gather necessary information for successful authorizations and appeals.
• Prepare and submit detailed appeal letters and supporting documentation to insurance companies for denied authorizations.
• Provide guidance and mentorship to Authorization Specialist I team members on complex cases and best practices.
• Develop and maintain strong relationships with key contacts at various insurance payers.
• Proficient in using computer systems and software, including electronic health records (EHR) and payer portals.
• Proficient in Microsoft Outlook, Microsoft Word/Excel, computer knowledge to navigate internet websites such as Availity, MyAbility, Relias, Cerner, etc.
• Proven ability to navigate complex payer requirements and resolve challenging authorization issues.
• Stay abreast of changes in payer rules, regulations, and industry best practices.
• Possess accurate data entry skills.
• Develop and maintain strong relationships with key contacts at various insurance payers.
• Communicate effectively with patients, physicians, clinical staff, and insurance representatives regarding authorization status and requirements.
• Follow up on pending authorizations and proactively address any issues or denials.
• Identify trends in authorization denials and work proactively with leadership to implement process improvements and training initiatives.
• Certified Patient Account Representative (CPAR) and Certified Revenue Cycle Representative (CRCR) preferred but not required.
• Strong organizational skills and attention to detail.
• Working knowledge of governmental regulations and other reimbursement criteria preferred.
• Experience in patient registration, verification and authorization in a medical center or comparable institution demonstrating the skill, knowledge, and ability to perform registration duties preferred.
• Assisi patients with understanding their insurance coverage and the authorization process.