The Specialist is responsible for obtaining and processing authorizations for Elective, Urgent, and Emergent inpatient and outpatient surgical and non-surgical admissions. The Specialist is also responsible for obtaining authorizations for outpatient Imaging, Hematology/Oncology, Cardiology testing, Day Medicine, Audiology, Physical Therapy, and any other assigned outpatient services. Elective authorizations are obtained prior to the admission/service date according to department standard. Emergent/Urgent notifications are to be initiated at the time of admission and must be completed according to the insurance company's notification requirements. During the authorization and notification process. The Specialist will provide the payer with all required patient information by fax, phone, or online submission. This role is required to utilize all available resources to verify eligibility, benefit levels, and patient copayment/coinsurance responsibilities. Estimates are prepared during the authorization process. It is imperative that the Specialist interprets the benefits correctly for an accurate estimate according to the patient's benefits. This position collaborates with Financial Services, Care Management, Preadmission Specialist, ED Access Staff, Transport Staff, Physicians, and Departmental Administrative Staff. The Specialist utilizes daily reports and workqueues to complete follow up on pending cases and assure an authorization is secured prior to admission date according to department standards. Should any service approaching the admission date not have a completed authorization, the Specialist will follow the Administrative Approval process. The Specialist will attend and participate in daily departmental huddles to report on payer issues, barriers affecting workflows, and specific issues that could result in a non-reimbursable or canceled service. The Specialist is required to provide excellent, customer focused and efficient service to both internal and external customers and represent Nemours in a positive, professional manner. The Specialist will have the ability to cover for any authorization, participate in organizational committees/task forces, attend payor meetings, and demonstrate effective utilization of EPIC applications as indicated by performance measures. This position will also assist with new associate training.

Essential Functions-

1. Ensure request for authorization is timely and handled in accordance with departmental policy and payer requirements.
2. Accurately verify patient demographics, insurance eligibility, benefits, and financial responsibility.
3. Ability of request and obtain preauthorization for assigned specialties and be able to cover for other specialties including workqueues, preadmissions, estimates, etc.
4. Build and maintain professional, cooperative relationships with all departments that have direct or indirect impact on obtaining authorizations.
5. Contact families in person or by phone contact to obtain necessary information and assist them with insurance issues and/or handle direct PA and DE Medicaid newborn enrollment.
6. Prepare estimates for scheduled services. Must interpret patient's benefits correctly for accurate estimates.
7. Clearly document all communications and contacts with payers, physicians, and families in standardized documentation requirements including proper format. Communicate effectively, timely and professionally in writing and verbally.
8. Consistently demonstrates excellent, empathetic, and knowledgeable customer service skills to internal and external customers
9. Collaborates with Financial Services for newborn enrollment, Medicaid enrollment/re-enrollment, self-pay referrals, estimates and Nemours funding.

Follow all newly implemented workflows including those developed by Continuous Improvement projects. Participation in CI projects may be required as Supervisor/Manager determines.

Qualifications-

High School Diploma

Revenue Cycle Related Certification

Authorization Experience required