The Specialist-Authorization is responsible for initiating a Pre-Authorization request to the payer for the claims that require approval. This position requires communication with payers, patients, physician offices, and hospital clinical staff. This position is primarily responsible for pre-certifying procedures ordered by physicians. The Specialist-Authorization will also be responsible for monitoring appropriateness and medical necessity, and providing necessary information for authorization and continued visits. This individual will confirm pre-certifications that have been obtained or will obtain pre-certifications if needed.
- Serve as primary contact for all SEHA Business Entity prior authorization requirements
- Serve as the primary resource for SEHA Business Entity reading of prior authorization process and requirements;
- Collect clinical information regarding services to be rendered;
- Contacts insurance companies by phone, fax, or online portal to obtain insurance benefits, eligibility, and authorization information;
- Updates systems with accurate information obtained;
- Responsible for communicating to service line partners of situations where rescheduling is necessary, due to lack of authorization or limited benefits and is approved by clinical personnel;
- Works with inpatient accounts for authorization and held responsible for timely notification to payers of the patient’s admission to the facility to protect financial standing;
- Uses utmost caution that obtained benefits, authorizations, and pre-certifications are accurate according to the actual test and procedure or registration being performed;
- Ensures all benefits, authorizations, pre-certifications, and financial obligations of patients, are documented on account memos, clearly, accurately, precise, and detailed to ensure expeditious processing of patient accounts;
