Referral Authorization Coordinator, Pharmacy

Req#: R27599
Category(s): Finance, Billing
Full Time / Part Time: Full-Time
Shift: First

Summary: 

The Referral Authorization Coordinator is responsible for providing a variety of support services that are essential to the efficient operation of adult and pediatric specialty practices' centralized process for insurance verification and authorization. Demonstrates excellent communication, interpersonal communication, critical thinking, and problem solving skills. Uses CIS as a means of multidisciplinary communication. completes all appropriate forms, applications, and information for departmental statistics. Accurately manages the referral and authorization process in a timely manner. Able to meet time-sensitive timelines for care treatment. Is pro-active in troubleshooting instances which could result in great financial loss. Demonstrates excellent customer service skills and works in a positive manner for collaboration and clear communication between providers, staff, insurers, and families. The specialist works closely with the clinical department staff, Care Coordinator, Social Service staff as well as the business services staff in the the performance of duties for information gathering and patient data. Participates in departmental meetings and meets all timelines for reports. Meets expectations for less than one week turnaround for majority of prior authorization approvals.

Job Responsibilities: 

1) Instructs and provides guidance to all specialties (adult and pediatric) staff regarding procedures and instructions for obtaining third party insurance authorizations. Prepares and distributes summary documentation of payor specific authorization requirements to key stakeholders.

2) Ensures all referrals and authorizations are obtained and processed in a timely fashion on both a complex and as-needed basis. Completes prior authorizations and referrals for services and testing in both A and B spaces. Develops and maintains a centralized prior authorization process utilizing all available systems.

3) Enters referrals and authorizations in to the system per standardized practice protocols/departmental guidelines and provides feedback to ordering provider and patient/parent in a timely manner. Monitors linkage of authorizations and referrals to appointments in Centricity, ensures compliance to insure proper payment for services provided.

4) Consistently monitors and works denial and no referral reports to obtain prior authorizations and referrals. Coordinates and processes documentation necessary for insurance appeals related to referral and authorization as well as other appeals as necessary for any/all services. Works with key stakeholders to track the denial and appeal process.

5) Maintains solid knowledge of utilization, billing, and reimbursement practices as well as special payor agreements specific to specialties. Prevents denials by identifying and documenting payor requirements for utilization management by employing a variety of methods including websites, contracts, policy manuals, bulletins, and other subject matter experts.

6) Coordinates and maintains the Electronic Referral Tracking Report for accuracy of information, urgency, and other designated criteria.

7) Documents and provides updates in the patient's medical record regarding the status of the referral and/or authorization.

8) Assists with billing and coding issues within 10+ divisions. Assists patient/families with billing, coding, and insurance issues.

9) Act as a resource to all internal and external customers, offering guidance and support for referral and authorization related questions and processing problems. Ensures patients/families receive timely and courteous communications.

10) Provides in-service training to other departments to explain referral/prior authorization process and methods to prevent non-payment. Works with staff and management to insure proper and accurate gathering and recording of payor information.

11) Assists divisions with complex, multi-study bookings (CT, MRI, PSG) that need to be booked together for family convenience and patient comfort.

12) Maintains statistical information and reports as directed. Participates in and drives process change to improve efficiency and decrease denials.

13) Coordinate strategy and re-evaluate claims to be written off by PBO in effort to exhaust all payment possibilities. Track reimbursement recovered.

Required Work Experience: 

1) 2+ years of prior authorization experience, including denial involvement

2) Experience using CIS inbox, CIS pools and EMR

3) Experience processing/submitting insurance prior authorizations’

Skills and Competencies: 

1) Knowledge of medical terminology preferred,

2)  Solid verbal and written communication skills

3)  Demonstrates a high degree of self motivation and self direction

4) Proficiency in Microsoft Office, Word, and Excel

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.

DIVERSE TEAMS. DIVERSE PATIENTS. DIVERSE LOCATIONS.

Education:

Associate of Arts, GED or HiSET (Required)

Certifications:

Equal Employment Opportunity Employer

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