JOB SUMMARY

The Authorization Specialist is responsible for facilitating and successfully procuring outpatient insurance authorizations. The Authorization Specialist will be accountable to one or more designated service lines across all sites of service to ensure payor requirements are met and authorizations are obtained timely and appropriately prior to service. The Authorization Specialist will provide subject matter expertise in the payor authorization process, identify changes in payor authorization requirements and communicate areas of opportunity for process improvement from a workflow and technology perspective to the leadership team.

REQUIRED QUALIFICATIONS*

• High school diploma in combination with 2-3 years’ experience working with health insurance or in a healthcare setting is essential.
• Outstanding customer service, written and verbal communication skills are mandatory.
• Ability to prioritize and handle multiple tasks, producing high-quality work in a timely, accurate and efficient manner is required.
• Proficiency in the use of computers and basic software applications is necessary.
• Ability to be flexible and work within a team-focused, participative management framework is required.

DESIRED QUALIFICATIONS*

• An Associate’s Degree with two years of progressively complex healthcare registration, medical or surgical specialty clinic and/or insurance experience is preferred.
• Understanding and knowledge of insurance benefits, third party payor rules and regulations is preferred.
• Familiarity with medical terminology, ICD-10 and CPT codes is desired.
• Experience working in the EPIC system is desired.

• Complete all aspects of the insurance pre-authorization process within required timeframes.
• Apply appropriate CPT codes for planned outpatient services and provide codes and clinical documentation to payors utilizing payor specific communication protocols.
• Prioritize and procure all required authorizations prior to service reducing appointment cancelations and reschedules due to no authorization.
• Act as a subject matter expert in insurance authorization requirements and timeframes including but not limited to in office procedures, in office medication/injections, diagnostic testing and external high-end imaging requests.
• Act as a referral coordinator and central resource/liaison for the assigned specialties across all sites of service, ordering providers and insurers.
• Verifies insurance coverage and identifies patient financial liability
• Provide timely communication to the authorization team and leadership regarding changes in payor requests or requirements that directly impact the procurement of authorization.
• Assist in the coordination of peer-to-peer reviews between the servicing provider and medical directors at the insurance company when appropriate.
• Clearly and thoroughly document all actions, payor and patient contacts, authorization outcomes and interventions following standardized workflow processes.
• Respond and address insurance related questions from Michigan Medicine customers and patients promptly and thoroughly.
• Obtain retro authorizations on billed and rejected claims and denied procedure codes for facility and professional services. Initiate appropriate follow-up actions in response to information obtained and document outcomes.
• Refer patients with complex insurance concerns requiring immediate attention to the Patient Financial Clearance or Financial Counselor or alternate funding sources as needed.
• May act as a resource to mentor and educate new hires.
• Attend and participate in operational meetings, utilizing LEAN thinking and principles. Work collaboratively with the team to develop standardized processes and incorporate efficiencies into daily workflow.
• Assist and contribute to the overall achievement of the Michigan Medicine and PreService Revenue Cycle quality, operational and financial goals and objectives.