JOB DESCRIPTION

Job Title	Insurance Authorization Specialist	FLSA	Non-Exempt
Reports to	Manager, RCM	Grade	E
Location	Remote	Band	1B

Summary/Objective
Under limited supervision the Insurance Authorization Specialist reviews and manages the benefits and authorizations for hospitals and physicians. This type of specialist acts as an intermediary between the medical institution, patients, and the insurance agency. They assist in verifying benefits and obtaining authorizations for inpatient and outpatient services.

Essential Job Functions

Maintain work queue assigned by the client
Verify benefits and secure auth or inpatient and outpatient services.
Performs other duties as directed.
Perform duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance.

Key Success Indicators/Attributes

Ability to prioritize and multi-task in a fast-paced, changing environment.
Demonstrate ability to work in all work types and specialties.
Demonstrate ability to self-motivate, set goals, and meet deadlines.
Demonstrate leadership, mentoring, and interpersonal skills.
Demonstrate excellent presentation, verbal, and written communication skills.
Ability to develop and maintain relationships with key business partners by building personal credibility and trust.
Maintain courteous and professional working relationships with employees at all levels of the organization.
Work in accordance with corporate and organizational security policies and procedures, understand personal role in safeguarding corporate and client assets, and take appropriate action to prevent and report any compromises of security within scope of position.
Demonstrate excellent analytical, critical thinking and problem-solving skills.
Manage the Individual KRA’s as per the provided metrics.
Understand client requirements and specifications of the project and ensure targeted collections are met on a daily / monthly basis.
Meet the productivity targets of clients within the stipulated time. Ensure timely follow-up on pending claims and prepare and maintain individual status reports.
Skill in operating a personal computer and utilizing a variety of software applications is essential.
Knowledge of coding convention and rules established by the AHIMA, American Medical Association (AMA), the American Hospital Association (AHA) and the Center for Medicare and Medicaid (CMS), for assignment of diagnostic and surgical procedural codes is an added advantage.
Knowledge of JCAHO, coding compliance and HIPAA HITECH standards affecting medical records and the impact on reimbursement and accreditation is an added advantage.

Supervisory Responsibility

Work Environment

This job operates in a remote home office environment. This role routinely uses standard office equipment such as computers and phones.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; and talk or hear. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus.

Position Type/Expected Hours of Work

This is a full-time position. Days and hours of work are generally Monday through Friday, 8:00 a.m. to 5 p.m. This position occasionally requires long hours and weekend work.

Travel

Minimal travel required; up to 5%

Required Education and Experience

Knowledge of medical and insurance terminology such as CPT, ICD-9, ICD-10, HCPCS, co-pay, deductible or co-insurance, and full understanding of hospital/physician billing. Minimum 1-2 years’ experience in Medical Billing/Coding and experience with standard office software products. High School diploma or equivalent.

Preferred Education and Experience

N/A

Additional Eligibility Qualifications

N/A

Security Access Requirements

In addition to the specific security access required by the employee’s client engagement, the employee will have access to the Omega set forth in the “Omega Field Employee” profile.

Equal Employment Opportunity:

Omega Healthcare is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment without regard to their race, color, religion, national origin, gender, age, sexual orientation, gender identity or expression, marital status, mental or physical disability, protected veteran status, and genetic information, or any other basis protected by applicable law. Omega Healthcare also prohibits harassment of applicants or employees based on any of these protected categories.

Omega Healthcare makes reasonable accommodations when needed for applicants and candidates with disabilities or religious observances. If reasonable accommodation is needed to participate in the job application, interview, or any other part of the hiring process, please contact Human Resources at [email protected].

Other Duties

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. Employee may perform other dut6ies as assigned

Description of Position:

Provide a “snapshot” or the principal purpose or focus of the position, consisting of no more than three to five sentences. This summary should provide enough information to differentiate the major function and activities of the position from those of other positions.

Obtains insurance eligibility, benefits, authorizations, pre-certifications and referrals for inpatient and outpatient, scheduled and non-scheduled visits. Updates demographic and insurance information in system as needed. Primary documentation source for access and billing staff. Resolve accounts on work queues. Work with insurance companies to appeal denials. Interacts in a customer-focused and compassionate manner to ensure patients and their representatives needs are met.

Essential Functions/Responsibilities:

Essential functions are the duties and responsibilities that are essential to the position (not a task list). o not include if less than 5% of work time is spent on this duty. Be specific without giving explicit instructions on how to perform the task. Do not include duties that are to be performed in the future. Duties should be action oriented and avoid vague or general statements.

% of Time

(annually)

Insurance Verification/Certification

Obtains daily work from multiple work queues to identify what is required by CBO.
Work with providers to assure that CPT and ICD-10 code is correct for procedure ordered and is authorized when necessary.
Completes eligibility check and obtain benefits though electronic means or via phone contact with insurance carriers or other agencies and when necessary/requested provide initial clinical documentation.
Initiates pre-certification process with physicians, PHO sites or insurance companies and obtains pre-cert/authorization numbers and adds them to the electronic health record and other pertinent information that secures reimbursement of account.
Perform follow-up calls as needed until verification/pre-certification process is complete
Thoroughly documents information and actions in all appropriate computer systems
Notify and inform Utilization Review staff of authorization information to insure timely concurrent review
Validates or update insurance codes and priority for billing accuracy.
Works with insurance companies to obtain retroactive authorization when not obtained at time of service.
Works with insurance companies, providers, coders and case management to appeal denied claims.
Responsible for following EMTALA, HIPAA, payer and other regulations and standards.
Responsible for meeting daily productivity and quality standards associated with job requirements.

75%

Customer Services

Adheres to department customer service standards.
Perform research to resolve customer problems
Collaborate with other departments to assist in obtaining pre-authorizations in a cross functional manner
Develop and implement prior authorization workflow to meet the needs of the customers.
Readily identifies work that needs to be performed and completes it without needing to be told.
Coordinates work to achieve maximum productivity and efficiencies
Monitors and responds timely to all inquiries and communications.

15%

Basic UPH Performance Criteria

Demonstrates the UnityPoint Health Values and Standards of Behaviors as well as adheres to policies and procedures and safety guidelines.
Demonstrates ability to meet business needs of department with regular, reliable attendance.
Employee maintains current licenses and/or certifications required for the position.
Practices and reflects knowledge of HIPAA, TJC, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.
Completes all annual education and competency requirements within the calendar year.
Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of hospital administrative staff. Takes appropriate action on concerns reported by department staff related to compliance.

10%

Disclaimer: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.

Demonstration of UPH Values and Standards of Behaviors Consistently demonstrates UnityPoint Health’s values in the performance of job duties and responsibilities
Foster Unity:	Leverage the skills and abilities of each person to enable great teams. Collaborate across departments, facilities, business units and regions. Seek to understand and are open to diverse thoughts and perspectives.
Own The Moment:	Connect with each person treating them with courtesy, compassion, empathy and respect Enthusiastically engage in our work. Accountable for our individual actions and our team performance. Responsible for solving problems regardless of the origin.
Champion Excellence:	Commit to the best outcomes and highest quality. Have a relentless focus on exceeding expectations. Believe in sharing our results, learning from our mistakes and celebrating our successes.
Seize Opportunities:	Embrace and promote innovation and transformation. Create partnerships that improve care delivery in our communities. Have the courage to challenge the status quo.

QUALIFICATIONS:

Minimum Requirements

Identify items that are minimally required to perform the essential functions of this position.

Preferred or Specialized

Not required to perform the essential functions of the position.

Education:

Requires minimally a High school diploma or GED.

Two years of experience in a hospital patient access/patient accounts department, medical office/clinic or insurance company is desired.

Experience:

Previous customer service experience.
Experience interacting with patients and a working knowledge of third party payers.

Prior experience with verification, and payer benefit and eligibility systems is preferred.

License(s)/Certification(s):

Valid driver’s license when driving any vehicle for work-related reasons.

Knowledge/Skills/Abilities:

Ability to perform a variety of tasks, often changing assignments on short notice.
Must be adept at multi-tasking
Will be required to learn and work with multiple software/hardware products (sometimes concurrently) during the course of an average work day
Must possess excellent communication skills, verbal and listening.
Must be able to maintain a professional demeanor in stressful situations.
Adept with machinery typically found in a business office environment.
Mathematical aptitude to make contractual calculations and estimate patient financial obligations.
Able to build productive relationships with all contacts.
Must be able to perform data entry with speed and accuracy

Knowledge of Medical Terminology is preferred.
Knowledge of benefits and language is preferred.

Other:

Use of usual and customary equipment used to perform essential functions of the position.

Qualifications

Preauthorization Specialist
Obtains insurance eligibility, benefits, authorizations, pre-certifications and referrals for inpatient and outpatient, scheduled and non-scheduled visits. Updates demographic and insurance information in system as needed. Primary documentation source for access and billing staff. Resolve accounts on work queues. Work with insurance companies to appeal denials. Interacts in a customer-focused and compassionate manner to ensure patients and their representatives needs are met.
Insurance Verification/Certification

•    Obtains daily work from multiple work queues to identify what is required by CBO.
•    Work with providers to assure that CPT and ICD-10 code is correct for procedure ordered and is authorized when necessary.
•    Completes eligibility check and obtain benefits though electronic means or via phone contact with insurance carriers or other agencies and when necessary/requested provide initial clinical documentation.
•    Initiates pre-certification process with physicians, PHO sites or insurance companies and obtains pre-cert/authorization numbers and adds them to the electronic health record and other pertinent information that secures reimbursement of account.
•    Perform follow-up calls as needed until verification/pre-certification process is complete
•    Thoroughly documents information and actions in all appropriate computer systems
•    Notify and inform Utilization Review staff of authorization information to insure timely concurrent review
•    Validates or update insurance codes and priority for billing accuracy.
•    Works with insurance companies to obtain retroactive authorization when not obtained at time of service.
•    Works with insurance companies, providers, coders and case management to appeal denied claims.
•    Responsible for following EMTALA, HIPAA, payer and other regulations and standards.
•    Responsible for meeting daily productivity and quality standards associated with job requirements.

Customer Services
•    Adheres to department customer service standards.
•    Perform research to resolve customer problems
•    Collaborate with other departments to assist in obtaining pre-authorizations in a cross functional manner
•    Develop and implement prior authorization workflow to meet the needs of the customers.
•    Readily identifies work that needs to be performed and completes it without needing to be told.
•    Coordinates work to achieve maximum productivity and efficiencies
•    Monitors and responds timely to all inquiries and communications.

Requirements
Education: Min: High school diploma
Preferred: Two years of experience in a hospital patient access/patient accounts department, medical
office/clinic or insurance company is desired.

Experience: Min: Previous customer service experience. Experience interacting with patients and a working knowledge of third party payers.
Preferred: Prior experience with verification, and payer benefit and eligibility systems is preferred.

License(s)/Certification(s): None

Knowledge/Skills/Abilities:
Min:
•    Ability to perform a variety of tasks, often changing assignments on short notice.
•    Must be adept at multi-tasking
•    Will be required to learn and work with multiple software/hardware products (sometimes concurrently) during the course of an average work day
•    Must possess excellent communication skills, verbal and listening.
•    Must be able to maintain a professional demeanor in stressful situations.
•    Adept with machinery typically found in a business office environment.
•    Mathematical aptitude to make contractual calculations and estimate patient financial obligations.
•    Able to build productive relationships with all contacts.
•    Must be able to perform data entry with speed and accuracy

Preferred:
• Knowledge of Medical Terminology is preferred.
• Knowledge of benefits and language is preferred.

Other:
Epic Experience preferred
Experience with multiple emails/teams preferred

Company

Founded in 2003, Omega Healthcare Management Services® (Omega Healthcare) empowers healthcare to thrive via intelligent solutions that optimize revenue cycle operations, administrative workflows, care coordination, and clinical research on a global scale. The company works with providers, payers, life science companies, medical device manufacturers, health technology firms, researchers, and industry partners to amplify teams with robust technology, specialty expertise, and operational support. Omega Healthcare serves more than 350 healthcare organizations with 35,000 skilled workers in the United States, India, Colombia, and the Philippines. For more information, visit www.omegahms.com

We offer a comprehensive benefits package that may include health, dental, and vision coverage, voluntary insurance options, a 401(k) plan with employer match, professional development opportunities, paid time off, and holiday pay. Eligible employees may also have the opportunity to participate in bonus programs, commissions, or other variable incentive plans. Benefits and incentive eligibility may vary based on position, location, and tenure.

AAP/EEO Statement