Authorization Representative

Job Details

Job Description

• Collaborates with physicians and provider office staff in secure the appropriate authorization, referral based on medical necessity and the patients’ treatment plan.
• Performs medical necessity review to ensure procedures and diagnoses meet payer requirements.
• Obtain authorizations in compliance with network policies and communicates any exception to ordering office, patient, and manager).
• Interfaces with insurance companies, both directly and indirectly, to verify coverage, benefits and obtain precertification.
• Reviews and verifies additional clinical information, insurance authorizations and referrals as needed.
• Monitors work queues and patient schedules to ensure accurate authorization are in place prior to each visit.
• Maintains compliance with benchmark metrics for accounts registered versus scheduled procedures.
• Calculates estimated patient financial responsibility using insurance verification, payer contracts, and self-pay guidelines. and/or self-pay guidelines.

• High School Diploma/GED
• 1 year experience in healthcare insurance verification, prior authorization requirements, and insurance benefits structures.
• Experience working with multiple insurance payers and understanding medical necessity requirements.
• Priorexperience working with electronic health record (EHR) systems and insurance portals.
• Familiarity with clinical documentation and interpretation of treatment plans.
• Knowledge of CPT, ICD-10 and HCPS coding as it relates to authorizations
• Knowledge of patients right and laws relative to patients rights such as HIPPA

• Associate’s Degree in health administration, healthcare management or related field preferred.

Work Shift

Worker Sub Type

Employee Entity

Primary Location Address

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.    

Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. 

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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