Clinical Authorization Specialist

Location : Commerce Place

Category : Professional and Management

Department : Central Referral Dept

Job Type : Full Time

Union Name : Non Union

Work Schedule: Day

Length Of Shift(s) In Hours : 8

Shift Details: Monday through Friday 8:00 am-4:30 pm

Hours/Week: 40

Weekend Requirements: no

Holiday Requirements: no

On Call Requirements: no

The Central Referral Department provides critical oversight of the revenue cycle for Cambridge Health Alliance including actively participating in front end and back end processes.

Job-Specific Duties and Responsibilities

• Performs prior authorization requests for various services requested by third party insurances
• Current services include but are not limited to:
• Advanced imagining
• High cost pharmaceuticals
• Surgical day procedures
• Obtains authorization for high cost items such as sleep studies, cardio lab, genetic testing, nuclear medicine, not limited to other high cost procedures
• These requests may be telephonic, via paper, or other means such as web based insurance portals
• These prior authorizations are typically clinical in nature
• Gathers medical information upon which to base a decision, forward clinical documentation to begin the decision by the insurance company, or educate providers on appropriate guidelines for a given service
• Reviews referral/authorization requests based on medical necessity through the application of approved clinical criteria and assessment of the individual needs of member and in conjunction with the provider’s request
• In preparation to speak with insurance company, reviews provider request, pertinent clinical encounters, exams and tests using CHA medical record system(s) and EMR
• Reviews specific medical terms, diagnosis or procedure and follows procedures for obtaining authorization request; requests additional information from the provider as needed to complete the process
• Speaks to insurance company’s medical management department or utilizes specific web based tools to determine if clinical information meets medical necessity criteria or requires additional medical necessity review
• Notifies ordering physician or rendering service provider of the preauthorization determination decision when peer to peer MD review is needed
• Documents the results of the clinical review and determination on the pre-certification paperwork; documentation is typically completed in Epic
• Maintains confidentiality of patient and provider specific information
• Maintains telephone service standards in accordance with departmental performance standards
• Maintains accurate and current information for tracking and quality assurance purposes
• Meets documentation standards and internal turnaround time for the authorization process
• Complies with all documentation and data entry processing related to internal systems, databases, and applications
• Serves as a collaborative resource and conduit between the CRO, provider, insurance company, and patient if necessary searches third party or regulatory changes and proactively monitors new requirements around clinical authorizations
• Participates in establishing and identifying cost-effective protocols, and develops guidelines for care; this may include effective utilization of Epic, Smart Sets, and other tools to facilitate documentation and communication across different clinical and financial departments
• Assists with development and implementation of IT enhancements and changes related to the authorization process
• Participates in all staff meetings planned and unplanned troubleshooting with leadership
• Maintains professional and technical knowledge by attending educational workshops
• Recognizes, troubleshoots and tracks patient-related problems and escalates chronic or systemic problems to Department Manager and Supervisor
• Maintains excellent interpersonal skills demonstrating a professional, caring attitude in all interactions with health providers, patients, Alliance departments, outside service agencies and consulting providers.
• Reports to work as scheduled and ready to receive assignments; minimal unscheduled absences
• Participates in quality improvement projects to improve efficiency and quality of the work delivered by the department. Identifies system need and areas for improvement and brings analysis to appropriate leadership team for resolution
• Demonstrates the ability to handle emergency situations in a prompt and professional manner
• Troubleshoots office equipment and calls the HelpDesk for assistance
• Provides high-quality customer service to patients and coworkers
• Treats patients and coworkers in a courteous and respectful manner
• Promotes a positive and productive environment
• Follows policies and department procedures as set forth by management
• Performs other related duties as assigned or directed.
• Ensures accurate insurance and demographic information are properly entered in the EPIC system
• Keeps supervisor and manager advised of any backlog
• Ensures accurate insurance and demographic information are properly entered in the EPIC

Organizational Duties and Responsibilities

• Responsible for creating a respectful environment for our patients and ourselves. Demonstrates respect for differences in language, culture, race, religion, citizenship, gender, and sexual orientation and does not discriminate on the basis of income, insurance status, immigration status, or disability.
• Complies with CHA policy on confidentiality of information regarding patients, families, and co-workers.
• Adheres to dress code; appearance is neat and clean.
• Completes annual educational requirements and in-service training as required.
• Wears identification while on duty.
• Reports to work as scheduled and ready to receive assignments; minimal unscheduled absences.
• Attends meetings and participates in committees as required.
• Follows policies and procedures as set forth by management. Performs all job functions in compliance with all Federal, State, Local and CHA policies or procedures
• Completes annual educational requirements and in-service training as required

Qualifications

• Two to five years of experience in Epic system within a Healthcare setting and/or a degree equivalent to the experience and a minimum of 1 year in a leading/supervisory position..
• The employee has proven outstanding productivity standards at all times and exceptional customer service excellence.
• Minimum of 2-4 years progressive experience interfacing with insurance companies in obtaining clinical authorizations preferred.
• Minimum of 2-4 years of current clinical experience in ambulatory care environment is preferred.
• At least 2 years experience in a medical outpatient setting
• Medical or Nursing Assistant program completion preferred.
• Portuguese, Haitian Creole, or Spanish language fluency preferred.
• Trained in the latest Epic upgrade.
• An effective team player with strong interpersonal skills.
• Good oral and written skills.
• Ability to interact and collaborate successfully with patients, network management and professional staff is essential.
• Computer literate. Proficient in Microsoft Office and Google Suite
• Clinical knowledge as may be acquired through authorization management experience an LPN, RN, Coder, Case Manager or other relevant field
• Ability to interpret 3rd party regulations
• Ability to obtain information from providers to support reasons for tests
• Prior experience with management of medical information, hospital information systems and other tools in patient care, particularly with Epic
• Demonstrated knowledge of CPT codes and ICD-10 -CM codes is preferred
• Ability to research and interpret documentation in patient records
• Working knowledge of insurance authorization portals and InterQual Review Criteria preferred.
• Solid analytical and computing skills including use of Google platform, spreadsheets, and internet searches to complete research
• Excellent phone/communication skills – able to convey key concepts clearly and succinctly
• Must possess a strong working knowledge of third party payers
• Personal flexibility to perform in an ever-changing work environment with frequent interruptions

Please note that the final offer may vary within the listed Pay Range, based on a candidate's experience, skills, qualifications, and internal equity considerations.

In keeping with federal, state and local laws, Cambridge Health Alliance (CHA) policy forbids employees and associates to discriminate against anyone based on race, religion, color, gender, age, marital status, national origin, sexual orientation, gender identity, veteran status, disability or any other characteristic protected by law. We are committed to establishing and maintaining a workplace free of discrimination. We are fully committed to equal employment opportunity. We will not tolerate unlawful discrimination in the recruitment, hiring, termination, promotion, salary treatment or any other condition of employment or career development. Furthermore, we will not tolerate the use of discriminatory slurs, or other remarks, jokes or conduct, that in the judgment of CHA, encourage or permit an offensive or hostile work environment.