Call Center Authorization/Quality Specialist

Work Shift

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advance technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Position Overview

Call Center Authorization/Quality Specialist

JOB CODE: 50847

FLSA Exemption Status: Non-Exempt

Summary (Basic Purpose Of The Job)

Ensures and completes authorization and auditing for outpatient testing services prior to services being rendered for optimal performance. Maintains complete knowledge of the pre-registration/scheduling system and department operational procedures and training guidelines to identify and audit charts for accurate demographic, diagnosis, and insurance information for all scheduled tests. Uses knowledge and skills of pre-registration scheduling requirements and applies them during chart review. Reviews all required information to ensure chart is complete.

Minimum Requirements

Education: High school diploma or GED.

Experience: Five years of experience in patient scheduling or in a medical office role working with patient insurance. Experience in insurance verification and authorization preferred.

Other Credentials

Knowledge and Skills: Working knowledge of medical insurance plans. Proficiency in working with payors on-line portals, as well as Experian and Navinet preferred. Basic knowledge of medical terminology and diagnosis. Possesses strong skills in patient relations, pre-registration, scheduling, pre-certification, and auditing of all scheduled outpatient accounts.

Special Training: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to prepare and interpret bar graphs. Ability to utilize common sense understanding in order to carry out written, oral or diagrammed instructions.

Mental, Behavioral and Emotional Abilities: Ability to deal with problems involving several known variables in situations of a routine nature. Ability to effectively communicate information and respond to questions in person-to-person and small group situations with customers, clients, general public and other employees of the organization.

Usual Work Day: 8 Hours

REPORTING RELATIONSHIPS

Does this position formally supervise employees? No

Essential Functions

• Uses knowledge and skills of pre-registration scheduling requirements and applies them during chart review. Reviews all required information to ensure chart is complete.
• Performs chart review to identify if variation from quality registrations exists. Determines the need for process improvement. Identifies concerns and makes recommendations for review to improve processes.
• Communicates findings as appropriate to department management involved. Reports discrepancies to supervisor or manager to ensure corrective action is taken in a timely manner.
• Maintains complete knowledge of the pre-registration/scheduling system and department operational procedures and training guidelines to identify and audit charts for accurate demographic, diagnosis, and insurance information for all scheduled tests.
• Secures insurance authorizations and pre-certifications for outpatient services. Verifies pre-certification to ensure appropriate reimbursement.
• Maintains proper communication skills with physician offices to obtain needed information for authorizations. Obtains and reviews physician orders for medically necessity coverage requirements.
• Assists with development and implementation of new or improved processes. Maintains up to date knowledge with Insurance matrix, pre-registration and scheduling compliance, insurance applications, and other systems utilized by Central Scheduling.
• Possesses proficiency with all insurance plans and payor codes. Identifies payment source and secures all information required to ensure a billable and collectable account and avoid penalties or denials prior to the bill dropping.
• Maintains thorough understanding of payor requirements for authorization, pre-authorization, and referrals. Performs verification of benefits either electronically or by telephone according to department procedures and guidelines.
• Identifies and obtains required precertification, authorizations and referrals and audits all information in the appropriate scheduling and billing system.
• Possesses ability to understand and use audit reports for missing vital billing information. Reviews coordination of benefits and Medicare secondary payor guidelines to determine primary and secondary payer status.
• Assists with development and implementation of new or improved processes. Maintains knowledge and is proficient with On-Base, Gaffey, all insurance applications including Experian, Navinet, Cerner pre-registration functions, and other systems utilized by Central Scheduling/Pre-certification functions.
• Provides ongoing performance feedback, addresses problems, and assists with training of new employees. Verifies and documents competency and identifies and suggests ways to develop skills.
• Communicates new insurance rules, changes in policies, procedures and regulations as needed. Monitors compliance with regulatory, licensing, and accreditation standards.
• Facilitates quality improvement by reporting problems, concerns, and opportunities for increased revenue and decreased denials. Contacts patients prior to scheduled visit with inactive insurance coverage to obtain updated insurance information.
• Works closely with other hospital staff, providers, and patients to resolve any issues with missing or incomplete authorizations and pre-registration to provide a smooth process.
• Performs any other related duties as required or assigned.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

Frequent physical demands include: Sitting, Standing, Walking, Keyboard use/repetitive motion.

Occasional Physical Demands Include:

Continuous physical demands include:

Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 10 lbs.

Sensory Requirements include: Very Accurate 20/40, Near Vision, Accurate Far Vision, Minimal Color Discrimination, Minimal Depth Perception, Accurate Hearing.

Anticipated Occupational Exposure Risks Include the following: N/A

Offers are contingent upon successful completion of our onboarding process and pre-employment physical. Capital Health will require all applicants to have an annual flu vaccine prior to start date, with the exception of individuals with medical and religious exemptions.

Company will never ask candidates for social security numbers or date of birth during application phase. If you are asked for this information online, you may be a target for identity theft.