This position is responsible for the accurate input of authorization data, checking of benefits and criteria on authorization requests and approval of designated authorizations. This position is also responsible for the day-to-day flow of authorizations to ensure data entry is accomplished in an accurate and timely manner.
ESSENTIAL FUNCTIONS AND ACCOUNTABILITIES:
- Adheres to and supports the mission, purpose, philosophy, objectives, policies, and procedures.
- Adheres to the HIPAA Compliance Plan and the Privacy Standards Confidentiality Agreement.
- Demonstrates support for the Corporate Compliance Program by being knowledgeable of compliance responsibilities as expressed in the Code of Conduct; adhering to federal and state laws, rules, regulations, and corporate policies and procedures policies that affect his/her specific job functions/responsibilities; and reporting compliance issues/concerns in a timely and appropriate manner.
- Checks for duplicates, and for accuracy of ICD-9 and CPT coding. Inputs codes in categories for documentation of urgent, retro and Third Party Liability (TPL) cap deducts.
- Ensures that the provider requested is a panel provider and appropriate to utilize.
- Researches and substantiates individual member’s health plan benefits, co-pays and benefit criteria. Checks eligibility when entering authorizations, documenting, and submitting eligibility requests.
- Documents pertinent related information in the memos and notes sections of the authorization. Releases/approves authorization as per guidelines.
- Identifies trends in physician offices with respect to referrals, etc. that may require education, and communicates this to appropriate department.
- Works in conjunction with the assigned health plan representatives to obtain necessary information.
MINIMUM QUALIFICATIONS REQUIRED:
- Education: High school diploma or GED required.
- Experience: Minimum 1-2 years in a managed care or HMO environment is preferred.
- Knowledge, Skills & Abilities: Strong organizational skills. Familiarity with medical terminology. Familiarity of CPT and ICD-9 coding. Strong typing skills at a minimum proficiency level of 60 wpm.
- Certification/Licensure: None required.