Authorization and Referrals Specialist

Winchester, MA, United States

Job Type: Regular

Time Type: Full time

Work Shift: Day (United States of America)

FLSA Status: Non-Exempt

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Ensures that all information necessary for proper financial reimbursement for high dollar patient care is analyzed and submitted to insurance companies for approval prior to the patient’s date of service. Collaborates with insurance companies when necessary to proactively validate benefits, eligibility and authorization requirements. Communicates with patients to assure they understand their payment obligations and steps necessary to meet these obligations, while maintaining a positive patient experience.

Job Description:

Essential Duties & Responsibilities including but not limited to:

Accesses work queues and reports and reviews patient accounts to determine financial clearance status of specific patient services. Takes action on those services without financial clearance.

Ensures demographic and patient contact information is complete and verified with the patient or patient representative.

Verifies the guarantor type and information and ensures it is assigned to the account correctly. This includes personal/family relations, workers compensation insurance, third parties, behavioral health or others as required.

Ensures all possible coverages are created and verified, through electronic or manual methods, and all discrepancies are resolved. Validates that coverages are assigned to appropriate visit.

Collects and validates order-related information including office visit, radiology and surgical orders. Follows up with ordering provider to verify CPT codes.

Verifies Primary Care Physician (PCP) information and ensures appropriate PCP referrals are in place for the provider and service by checking electronic systems and calling PCP offices. Enters and links referrals in system.

Processes referrals when necessary, assuring proper tracking and redirection when appropriate. Understands each clinical department’s referral certification protocols and ensure referrals are certified at the appropriate level.

Using system activities and functions, identifies non-covered services and prepares proper Advance Notice Beneficiary (ABN) or waiver for registration team. Documents account for registrar action.

Analyzes clinical documentation in support of ordered procedure(s) and submits precertification requests through various insurance fax lines, phone systems and web portals. Follows up on pending accounts and involves ordering provider offices as needed to obtain approvals.

Escalates challenging accounts to provider representative to ensure accounts are approved at least two weeks prior to patient appointment/surgery.

Collaborates with clinical departments to facilitate scheduling of approved procedures and rescheduling of non-urgent non-certified cases. Professionally communicates outcome to patient when needed.

Escalates non-certified urgent cases to appropriate clinical departments and leadership for approval to proceed or rescheduling.

Verifies covered benefits, including remaining hospital days, carve out coverages and benefit limits of visit and/or timeframe.

Contacts patients, providers and insurance companies to validate data, collect missing information and resolve information discrepancies,

Understands clinical guidelines for payors requiring authorization to better build cases for authorization requests and provide feedback to clinical departments on required notes.

Communicates with patients and discusses their financial clearance status when necessary. Explains the status of any services not financially cleared and advises patients of the proper resolution steps, including self-payment. Directs patients to Lahey Financial Counselors when appropriate.

Works with the Financial Counselors, clinical departments, outside providers, third party insurers and any other individual or entity to assist in resolving patient financial clearance questions or problems in the most effective and positive manner possible.

Researches claim edits and payment denials related to financial clearance and works closely with the Lahey Patient Financial Services staff to resolve these denials. Communicates resolution to patients.

Organizational Requirements:

Maintain strict adherence to the Lahey Health Confidentiality policy.

Incorporate Lahey Health Standards of Behavior and Guiding Principles into daily activities.

Comply with all Lahey Health Policies.

Comply with behavioral expectations of the department and Lahey Health.

Maintain courteous and effective interactions with colleagues and patients.

Demonstrate an understanding of the job description, performance expectations, and annual competency assessment(s).

Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.

Participate in departmental and/or interdepartmental quality improvement activities.

Participate in and successfully completes Mandatory Education.

Perform all other duties as needed or directed to meet the needs of the department.

Minimum Qualifications:

Education: High school degree or equivalent

Licensure, Certification & Registration: None

Experience: At least two years prior experience in a health care setting requiring knowledge of insurance coverage, reimbursement, and/or medical terminology and coding. Experience providing customer service, while processing and verifying electronic demographic, financial or other business-related information and data.

Skills, Knowledge & Abilities: Able to work successfully in a fast-paced, multi-task environment, where some independent decision making is necessary. Able to process electronic information and data accurately and efficiently.

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more (https://www.bilh.org/newsroom/bilh-to-require-covid-19-influenza-vaccines-for-all-clinicians-staff-by-oct-31) about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled