Nemours is seeking a Physician Authorization/Referral Specialist!

Candidates must live within the Delaware Valley.

The Specialist is responsible for obtaining and processing Elective, Urgent, and Emergent referrals and authorizations for physician based services and some office based services, including but not limited to cardiology, audiology test, laboratory testing. The Specialist is also responsible for obtaining genetic testing approval and medication authorizations and other assigned outpatient services. The Specialist will work with partner hospitals for claim submission and registration accuracy. They will also ensure that patient responsibility estimates are created and communicated timely. Elective referrals and authorizations are obtained prior to the service date according to the department standard. Urgent/Emergent referrals and authorizations are to be initiated at the time of the service and must be completed according to insurance company guidelines. Referrals and authorizations are obtained prior to the date of service as per department standards. During the authorization/referral process the specialist will provide the insurance company and or pcp office with all required patient information by fax, phone, or online submission. They will partner with the Primary Care Provider to obtain all approvals as needed per insurance company requirements. This role is required to use all utilize all available resources to verify eligibility, benefits and patient out of pocket responsibilities. Estimates are prepared during the authorization process for in office testing and procedures. The Specialist is also responsible for researching and notifying the servicing departments of co-payment responsibilities. It is the very important that the Specialist understand and interpret benefits correctly in order to communicate and estimate out of pocket responsibility according to the patients insurance benefit. Should a service date approach without prior authorization and or referral the specialist will follow the Administrative Approval process to ensure that patient responsibility is accounted for.

This position collaborates with: Hospital Authorization department, non Nemours physician offices, managed care department and Nemours Physicians, and Departmental Administrative Staff to ensure that accurate information is collected and distributed effectively and efficiently. The specialist will collaborate with partner hospital to s=ensure that claims are processed timely and effectively. They will also partner with outside resources such as Paths to ensure enrollment with Medicaid payers takes place timely. The Specialist utilizes daily reports and work queues to complete follow up on non-approved cases and assure completion prior to service date according to department standards. In addition, the Specialist will attend daily departmental 2 huddles to report on payor issues, barriers impacting workflows, and specific issues that could result in a nonreimbursable visit. The Specialist is required to provide excellent, customer focused and efficient service to both internal and external customers and represent Nemours in a positive, professional manner. In addition to the above listed responsibilities, the Specialist will have the ability to cover all referral and most authorization visit types, participate in organizational committees/task forces, attend payor meetings and demonstrate effective utilization of EPIC applications as indicated by performance measures. This position will also assist with new associate training and provide guidance around their specialty to other associates.

Responsibilities:

1. Ensure timely notification and request for authorization/referrals is handled in accordance with departmental policy and payor requirements.
2. Maintaining confidentiality, verify patient demographics, insurance eligibility, benefits, and financial responsibility.
3. Ability of request/obtain authorizations/referrals for assigned specialties and be able to cover for most specialties.
4. Communicate effectively, timely and professionally in writing and verbally
5. Contact and interview families in person or by phone contact to obtain necessary information and assist them with insurance issues that may be preventing authorization/referrals.
6. Clearly document all communications and contacts with payors and families in standardized documentation requirements including proper format
7. Consistently demonstrates excellent, empathetic and knowledgeable customer service skills to internal and external customers
8. Is aware and adheres to all State and Federal Regulations including, but not limited to: EMTALA, HIPAA, and the Joint Commission
9. Ability to review workflows and suggest improvements in specialty areas
10. Ability to work independently, prioritize workload and assist other associates as required.
11. Build and maintain professional, cooperative relationships with all departments that have direct or indirect impact on obtaining authorizations.
12. Prepare estimates for scheduled services. Must interpret patient's benefits correctly for accurate estimates.
13. Work with partner hospitals for claim submission and registration accuracy.
14. Timely patient responsibility creation and communication.

Qualifications:

• High School Diploma required
• Referral/authorization experience required
• CRCR preferred