Specialist-Authorization Denial

Specialist-Authorization Denial in Memphis, Tennessee, United States

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Specialist-Authorization Denial

Job ID: 39528

Job Category: Finance and Accounting

Work Type: Full Time

Work Schedule: Days

Department: Denial Mitigation

Facility: BMHCC System Services

Location: Memphis, TN

Overview

Purpose of Position and Scope of Responsibility

Authorization Denial Specialist ensures that chemotherapy (specialty group) and other infusions/radiation therapy/radiology/ surgical services meet medical necessity and appropriateness per insurance medical policies/ FDA/NCCN guidelines. Initiates and coordinates pre-certifications/prior authorizations per payer guidelines prior to services being rendered and completes the Insurance verification process.

Reviews clinical information and supporting documentation for outpatient or Part B services authorization denials to determine and perform retro authorizations, reconsiderations or appeal actions to defend the revenue. Performs other duties as assigned.

Principal Accountabilities/Responsibilities

• Obtain and review treatment/therapy plan orders for medical necessity and appropriateness according to insurance medical policy/FDA/NCCN guidelines and requirements.
• Research insurance company medical policies, medical literature, and compendiums to determine eligibility for services. Utilize multiple healthcare websites.
• Track, obtain, and extend authorizations from various carriers in a timely manner.
• Complete the Insurance Verification process.
• Works closely with physicians and clinic staff obtain authorizations to promote positive patient outcomes, timely treatment and positive reimbursement.
• Understands and complies with regulatory requirements by specific insurance companies and facilitates compliance by maintaining awareness of guidelines and ensuring compliance through communication and documentation to appropriate staff.
• Reviews, assesses and evaluates all authorization denial communications received in order to optimize reimbursement.
• Collaborates with denial team to education denial specialists and clinical staff on trending in authorization and medical necessity denials.
• Complete other duties as assigned.

Minimum Qualifications

3 - 5 years of business experience in a healthcare environment with 2 of those years being in a clinical setting.

Desired Qualifications

5 years of business experience in a healthcare environment with at least 3 years payer specific experience.

3 years clinical experience in a clinical care setting

Pre-certification experience desired.

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Baptist is an equal employment opportunity employer and prohibits discrimination based on an individual''s race, color, religion, national origin, pregnancy, sex, age, handicap, disability (physical, visual or mental), creed, marital and veteran status, genetic information or any other category protected by federal or state law, with respect to all aspects of the employment process, including recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.

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