Specialist - Authorization (Tawam Fertility Center)

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.

Required: •    12 years of Revenue Cycle Experience in lieu of degree.  •    Healthcare Certification (CRCR and/or CHAM)  •    Extensive knowledge of healthcare revenue cycle systems;  •    Minimum two (0-2) years of medical insurance verification and authorization required;  •    Billing and coding experience preferred;  •    Minimum of (0-2) years documented and recent experience in a medical facility setting where the use of the electronic system for complex coding, insurance issues, pre-certification, and outbound referral management is evident;  •    Experience, testing, or academic coursework completion of CPT, ICD-10, HCPCS, LMRPs, and similar coding/guidelines;  •    Experience with third-party payer requirements, contracts, authorization, and payment practices;  •    Understanding of insurance requirements for prior authorization;  •    Knowledge of registration, verification, pre-certification, and scheduling procedures;  •    Understanding of payer processes (website, fax, contact number) to submit appropriate clinical documentation;  •    Proficient knowledge of Microsoft Office and Outlook;  •    Proficient knowledge of Medical Terminology and Medical Coding;  •    Understanding of insurance billing procedures and practices;  •    1-3 years of prior authorization experience in a large healthcare, multi-integrated network, or third-party medical billing environment;  •    Knowledge of ICD-10 and CPT-4;  •    Experience with insurance terminology required.

Initiate a Pre-Authorization request to payers for claims requiring approval. Communicate with payers, patients, physician offices, and hospital clinical staff. Pre-certify procedures ordered by physicians. Monitor appropriateness and medical necessity, and provide necessary information for authorization and continued visits. Confirm pre-certifications that have been obtained or will obtain pre-certifications if needed.