Insurance Authorization Coordinator II - Cardiology (Finance)

Nemours is seeking an Insurance Authorization Coordinator II for our Cardiology Department.

The Insurance Authorization Coordinator II is responsible for obtaining authorizations for hospital-based and/or physician-based services.

The Coordinator II utilizes work queues & other mechanisms to initiate the authorization and/or referral, follow-up, monitor appointments add-ons, and document any changes available for the initial authorization and/or referral request. Authorizations/Referrals for services are to be completed based on the departmental goals and guidelines set. The position is required to utilize all available resources to verify eligibility, authorization requirements and plan benefit levels. Detailed benefit collection process to ensure capture of patient responsibility to include all financial out to pocket cost to patient/parent. Process supports and ensures more accurate financial collections. The Coordinator II has an expanded role as they cross trained in multiple areas and can handle more complex requests including communication with stakeholders.

Essential Functions:

Authorization Coordination: Ability to request and obtain preauthorization for assigned specialties and ability to cover for other workflows including work queue items. This will involve submitting required documentation, following up on requests to ensure timely approvals.

Ensure request for authorizations and notifications are worked timely and handled in accordance with departmental policy and payer requirements. Following all documentation requirements.

Insurance Verification: Verify patients' insurance coverage, eligibility, demographics, benefits and financial responsibility to determine if prior authorization is required for specific medical procedures or treatments; additionally, any predetermination requirements to ensure proper payment for service to support collection accuracy & efforts.

Policy Knowledge: Stay up to date with insurance policies, guidelines, and procedures related to authorization and reimbursement processes. This includes understanding specific requirements for different insurance companies and their medical coverage policies.

Properly process appointment or appt add-ons, changes to previously scheduled services, date changes, and or impactful service changes in need of immediate review.

Follow administrative review process if a service does not have an insurance authorization outside of the department's standard timeframe.

Communication: Communicate with patients, their families, and healthcare professionals to provide updates on the status of authorization requests, address questions or concerns, and ensure a smooth process for all parties involved.

Promptly review clinical documentation for necessary information to submit to the payer along with authorization request.

Documentation and Record-Keeping: Maintain accurate and detailed records of authorization requests, approvals, denials, and any related correspondence. This includes documenting patient information, insurance details, and the authorization process itself.

Collaboration: Collaborates with healthcare providers, physicians, and clinical staff, additionally the Central Business Office, Financial Services, Transport, Patient Cost Estimation, Managed Care, Utilization Review, dedicated Authorization Departments, and other departments that have impact on obtaining authorizations and/or reimbursement.

Problem-solving: Identify and address any barriers or challenges that may arise during the authorization process. This could involve working with insurance companies to resolve denials, appealing decisions, or finding alternative solutions for patients' medical needs.

The Specialist will attend and participate in daily departmental huddles to report on payer issues, barriers affecting workflows, and specific issues that could result in a non-reimbursable or canceled service.

The Specialist must be organized, work effectively in a virtual team environment, can problem solve, and seek assistance when needed.

Build and maintain professional, cooperative relationships with contacts from specialty departments. Consistently demonstrates excellent, empathetic, and knowledgeable customer service skills to internal and external customers.

Compliance: Adhere to relevant laws, regulations, and privacy guidelines when handling patient information and insurance-related documentation. Ensure all authorization processes are conducted ethically and in accordance with organizational policies.

Requirements:

High School Diploma Required

3 - 5 years auth experience required

Knowledge of insurance plans and third-party payor requirements

Understanding of CPT, ICD 10 codes and basic medical terminology required

Knowledge of, but not limited to, role appropriate Epic Applications.